Lady Mar writes to Prof Wessely

[Simon]

There's no doubt that Simon Wessely has a track record of seemingly-deliberate ambiguity about his views on CFS and the correspondence with Lady Mar initially looked like more of the same. I would also say his comment about the 'unstatisfactory' classification of somatoform disorders in his latest letter is similarly ambiguous.

However, having gone through his latest letter, and other people's comments on it, I still think there is a significant shift in his position and it would be a shame to dismiss it too easily.

I think that's the most unambiguous statement on the role CBT/GET I've seen from Simon Wessely.

What do you think he said?

Generally
I think he's saying that he thinks CBT & GET help CFS patients, but are not curative. For a liaision psychiatrist I don't think that's an unreasonable position to take, and does represent a significant shift away from an essentially psychogenic model of CFS.

Like Sean, I would like to see him put this in writing in a peer-reviewed journal. But rather than wait in vain for a spontaneous public recantation of the Biopsychosocial viewpoint of CFS, I'd like to see this possible opening with Simon Wessely explored. And it seems Lady Mar is planning to do just that.

More specifically
I think the heart of this is:

• regardless of the initial trigger, what perpetuates CFS for most patients?

A secondary question directly related to this is:

• what's happening in the minority (size unspecified) that do recover with CBT/GET?

In general I think that CBT/GET improves outcomes in CFS but does not make the majority of sufferers symptom free. I don't particularly like the word palliative in this context, but I think we mean the same thing.

However, on the basis of my extensive clinical experience and the published literature I do know that rehabilitative treatment can in a smaller proportion lead to a resolution of the illness. My hypothesis would be that in these instances the original factors have resolved, but the secondary handicaps of chronic illness remained. I emphasise again that this is not the reason that I recommend CBT or GET to patients.

Now for my contextual analysis (yawn).

First, there is a clear distinction between the majority that don't recover ("majority of sufferers... not symptom-free") and the minority that 'do' ("...in a smaller proportion lead to a resolution of the illness"). That itself is interesting.

My hypothesis would be that in these instances [recovery] the original factors have resolved, but the secondary handicaps of chronic illness remained.

This is probably the key sentence. It appears to be arguing for a classical biopsychosocial explanation for this minority: the 'original' factors have resolved and a secondary cycle perpetuates the illness. However, since this is applied explicitly to the minority, then for the majority there must be more to their CFS than 'secondary handicaps of chronic illness'. I don't think we should dismiss this.

In general I think that CBT/GET improves outcomes in CFS but does not make the majority of sufferers symptom free. I don't particularly like the word palliative in this context, but I think we mean the same thing

So here there is more ambiguity, but it still looks to me like a change. "Not symptom-free" on its own could simply mean patients are basically recovered but with an unhealthy focus on symptoms, so that effectively they have a psychosomatic condition. However, because of the later contrast with those with a full 'resolution' of the illness, plus my comments above and below, I don't think it's easy to interpret the statement that way.

Also, what does 'palliative' mean here? Often it's used to mean simply relief of suffering without any underlying cure eg morphine pain relief for those with terminal cancer. On the other hand, what if you believe CBT/GET can improve the underlying condition, but not cure it? That seems to be what Wessely is saying here and we would be a significant shift from a BPS viewpoint. 'Not-palliative' doesn't mean 'curative'. Certainly I believe that pacing does improve my underlying condition but definitely doesn't cure it; I might say it provides the optimal conditions for a degree of natural healing, but won't make me well.

Having said "I don't particularly like the word palliative in this context, but I think we mean the same thing", and in the context of this correspondence, I think it would be almost impossible for Wessely to subsequently argue that he thought he and Mar both considered CFS a psychosomatic condition responding to psychological treatment.

This is in line with PACE - only a small minority (13%) showed purely subjective improvement, even with all the flaws in the study which coincidentally were of an advantage to CBT/GET practitioners. I think, to some extent, all of the criticism and close attention to PACE has forced the BPS school to tone down their sales pitch somewhat, at least to an audience that includes ME patients and organizations.

I think you are right that this is a significant change in the 'sales pitch', in line with the results of PACE but not the spin placed on it by most of the authors.

But is this what he's saying to groups that don't include ME patients and orgs? Based on past examples, probably not.

I actually think this is different. Because of our slightly bonkers class and political system, correspondence with a peer of the realm carries particular weight, especially as it was an acknowledged open correspondence, explicitly about Simon Wessely's views on CFS. That gives a lot more importance to the views expressed in these letters, and makes them highly citable - and much harder for Wessely to later disclaim or fudge around.

I started off thinking this correspondence was a completely pointless exercise, but I now think it represents an opportunity that at this stage should be judged on its merits, not merely on the Simon Wessely's track record. There isn't going to be a 'Road to Damascus' conversion from Wessely and colleagues. If a genuine change ever came, it would probably start like this. That, of course, doesn't make this a genuine change, but I don't see what we have to lose by exploring the possibility.

 

[Simon]

Yet one of the reasons i've seen given for calling it CFS is that "fatigue best represents the patients experiance". Seems to me that many of the doctors pushing this view don't listen to patients about symptoms but rather have a symptom model in their mind and hence fit what people say into their model (which is that patients feel tired).

This seems to bring a much wider point which is around observation skills, interpretation and science. It is so important to make observations separate from interpretations hence the importance of good measurement equipment, When there are only subjective methods there is a huge danger that those making the observations interpret them at the same time or even ignore those that don't fit. Hence you get bad data, leading to bad theory. Where diagnostic methods are based on such subjective measures and ill defined terms this will lead to lumping and conflation of different symptoms under a single label.

I was wondering has someone actually tried to characterise what patients describe as fatigue in ME.

Lenny Jason has done some excellent work on trying to identify how ME/CFS fatigue differs from normal, healthy fatigue, eg http://dsq-sds.org/article/view/938/1113 and http://www.ncbi.nlm.nih.gov/pubmed/20656613. Such a distinction is obvious to patients but doesn't seem to have been grasped by many working in the field.

I also think Alex is right to stress fatigability over fatigue, and this is something that has received almost no serious attention from researchers.

 

[orion]

CFS is not classified as a somatoform disorder. Nor do I believe it should be. In addition, like many of my colleagues in liaison psychiatry, I think that the classification of somatoform disorders is unsatisfactory.

Hmm. At first glance, this statement appears to be a significant shift in his position, but on further inspection, it turns out to be typical Wessely sophistry.

Wessely is on record as saying that ME should be regarded as a 'Functional Somatic Syndrome' which is defined (by him) as follows:

"We define a functional somatic symptom as one that, after appropriate medical assessment, cannot be explained in terms of a conventionally defined medical disease."

link

In my opinion, the difference between a somatoform disorder and a functional somatic syndrome is wafer thin, but it gives Wessely just enough wriggle room to make the above statement without being accused of telling an outright lie. Nevertheless, the statement is, in my opinion, deliberately misleading, as he'll be aware that most lay people won't make a distinction between a functional somatic syndrome and a somatoform disorder.

In my opinion, Lady Mar should now ask Wessely whether he still regards ME as being a 'Functional Somatic Syndrome'.

 

[vli]

I actually think this is different. Because of our slightly bonkers class and political system, correspondence with a peer of the realm carries particular weight, especially as it was an acknowledged open correspondence, explicitly about Simon Wessely's views on CFS. That gives a lot more importance to the views expressed in these letters, and makes them highly citable - and much harder for Wessely to later disclaim or fudge around.

I totally agree. This is why I find these correspondences so interesting, because he has to be very bleeping careful about his answers.

 

[Valentijn]

Yes. In the past he's been able to take the position of strongly pushing the psychosomatic model, while leaving enough wiggle room to be hard to pin down in a nice little quote or two.

Now he's being forced to take the position of the non-psychosomatic model, while trying to leave some wiggle room for his colleagues to understand that he's not really changing his view or contradicting himself.

But by making statements that superficially (albeit not actually) reject the psychological theories, he might cause himself to be misinterpreted by those who do not understand his stance and slippery writing style. How hard would it be to take Wessely's letter to Mar and write a nice article about it with the headline "ME Psych Doctor Switches Sides - NO Psychosomatic Aspect to ME"?

I think that letter went far enough that most members of the public and even some of his colleagues would read it to say exactly that - which, far from merely saving his BPS-butt from committing to the psychosomatic model, could advertise and advocate for the biological model.

 

[urbantravels]

Ninety percent of post viral fatigue will automatically resolve. Only around ten percent becomes ME.

Alex, I'm going to ask you to pony up on a source for this! Not because I don't believe you, but because I'd like to be able to use the reference.

 

[urbantravels]

Why is it unsatisfactory? Because we understand what somatoform means? Does he prefer "medically unexplained symptoms" or "functional disorder", since those are unclear terms, even though the psychiatric world equates all of those terms as having the same causes (psychological) and treatments (psychological)? Finding the classification of "somatoform disorder" as unsatisfactory is not the same as denying that ME/CFS is a somatoform disorder.

Based on what little I've heard of the Wesseleyite school's interaction with other illnesses and conditions, it seems as though the problem may be that they want the role of the patient's "mistaken illness beliefs" to be recognized in many MORE diseases, besides the ones (like ours) that are most vulnerable to this form of misinterpretation.

I think the goal here may be to not use to the concept or term "somatoform" because it is TOO specific, and these folks in this particular branch of "liaison psychiatry" want to have more freedom to barge in on the conceptualization and treatment of other diseases. Everybody who is sick is suffering some emotional distress; why not blame the emotional distress for "perpetuating" the illness rather than understand how the illness is causing emotional distress? Why not throw CBT at *every* kind of illness - NOT as a therapy designed to help cope with the illness, but to persuade the patient that they can think their way out of their illness, potentially reducing their demands for actual medical care? Really, the sky's the limit.

 

[Sam Carter]

Alex, I'm going to ask you to pony up on a source for this! Not because I don't believe you, but because I'd like to be able to use the reference.

The Dubbo Infection Outcomes Study Group paper is a useful ref.

BMJ. 2006 Sep 16;333(7568):575.

Post-infective and chronic fatigue syndromes precipitated by viral and non-viral pathogens: prospective cohort study.

Hickie I, Davenport T, Wakefield D, Vollmer-Conna U, Cameron B, Vernon SD, Reeves WC, Lloyd A

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1569956/

 

[urbantravels]

Lenny Jason has done some excellent work on trying to identify how ME/CFS fatigue differs from normal, healthy fatigue, eg http://dsq-sds.org/article/view/938/1113 and http://www.ncbi.nlm.nih.gov/pubmed/20656613. Such a distinction is obvious to patients but doesn't seem to have been grasped by many working in the field.

I've been chewing on this problem on and off for some time. I compare it to pain evaluation. Doctors' understanding of pain is not all that sophisticated either, but at least there are some tools available to identify both quality and quantity of pain. I don't know about other countries, but here in the US there is a numerical "pain scale" that is widely used, often illustrated by a cute little chart like this one, pinned up in doctors' offices everywhere:

http://www.google.com/imgres?hl=en&...294&start=0&ndsp=17&ved=1t:429,r:11,s:0,i:190

Hope that link works. There are tons of versions of the "pain chart" available on Google Images, but I chose this one because it adds some text below the scale that you don't usually see, giving additional qualitative descriptions of type of pain and how it affects activity. There is definitely a *language* of pain available as well as a scale of severity - stabbing, burning, aching, throbbing, dull, sharp, focal, etc. These terms are widely used and understood by doctors, and the type of pain described is an important diagnostic clue.

Fatigue scales exist, but when was the last time you saw one hanging in a doctor's office? Or had any kind of doctor, (other than an ME/CFS specialist) ask you qualitative questions about your fatigue? When looking up ailments on the Internet, how often do you see "Fatigue" listed as a symptom along with some qualitative description of the *type* of fatigue?

The fatigue scales aren't widely known or widely adopted, and the language of fatigue is really quite impoverished compared to the language of pain. I experience a variety of types of fatigue within my illness, but I struggle to describe them to healthies - and believe me, I KNOW A LOT OF WORDS. Early in my illness, when I was undiagnosed and seeing specialists, I helpfully volunteered the most detailed descriptions of my fatigue I could manage, including the different types I experienced, a timeline of how it progressed throughout the day, how it changed when I did different things, etc. And I would see total incomprehension on the doctor's face as they attempted to politely listen. These descriptions were no use to them at all.

If a widely-understood language doesn't exist to describe types of fatigue with more precision, you get all kinds of dopiness, from clueless healthies who don't understand that the "fatigue" we are talking about is not just a bad version of "fatigue" as universally experienced by healthies, to doctors who don't know the significance of types of fatigue and can't use knowledge of those types to aid diagnosis.

 

[urbantravels]

Thanks, Sam - your post slipped in as I was churning out my long-winded posts.

 

[Esther12]

There's no doubt that Simon Wessely has a track record of seemingly-deliberate ambiguity about his views on CFS and the correspondence with Lady Mar initially looked like more of the same. I would also say his comment about the 'unstatisfactory' classification of somatoform disorders in his latest letter is similarly ambiguous.

However, having gone through his latest letter, and other people's comments on it, I still think there is a significant shift in his position and it would be a shame to dismiss it too easily.

Generally
I think he's saying that he thinks CBT & GET help CFS patients, but are not [consistently?] curative.

I just don't see anything in these letters which is a clear and significant change from what he's said elsewhere. Possibly you previously thought his views were worse than I did, so these letters are more a movement in your opinion? There is a lot of ambiguity over exactly what he means by certain things, so maybe he thinks these letters represent some massive break from his past views... but I doubt it. My guess would be that he is just now expressing his same views in a form intended to be read by patients rather than commissioners, doctors, the MRC, DWP, etc.

If Wessely were to say 'I think that it is wrong to treat patients with CFS as if dysfunctional cognitions and the behaviours they lead to are the most significant cause of ongoing disability' that would be significant. So far he's not said anything close to that.

 

[biophile]

Potential misinterpretations aside, the controversy has always been about the accuracy and degree of emphasis placed on the proposed distorted beliefs / unhelpful cognitions and maladaptive behaviours in CFS, not whether such factors could possibly exist at all in any illness. The models underlying CBT and GET present these factors as having major top-down explanatory power for the ongoing symptoms and disability of CFS, while biomedical disease factors are generally missing from these models when it comes to perpetuation.

Wessely has often been somewhat ambiguous about how important these factors are, although obviously important enough to call it the "cognitive behavioural model of CFS" (with its "vicious circle of fatigue"), write dozens of papers on it, and previously claim that after therapy about 1/3 recover and a further 1/3 are helped substantially (without giving control figures of course). Similar claims have been made by other proponents. However, the PACE Trial, the largest RCT on CBT/GET, demonstrated that only about 1/7 or 1/8 report subjective improvements due to these therapies, while those improvements on average are rather modest and may simply reflect palliation rather than rehabilitation.

IIRC, Wessely once confessed that he overestimated the association or similarities between CFS and depression. A similar confession should be forthcoming for the role of cognitive behavioural factors in CFS. I would respect him more if he did so. An acknowledgment that the nature of improvements is uncertain would also be helpful.

 

[alex3619]

Alex, I'm going to ask you to pony up on a source for this! Not because I don't believe you, but because I'd like to be able to use the reference.

Hi urbantravels, I can do that. Most significant viral infections induce fatigue, including even the common cold. In most cases this is due to our immunological response. After the virus resolves the immulogical responses resolve, but with a variable timeframe. So post-viral fatigue can last weeks or even months, and in some cases twelve months to five years. The classic study on this for CFS is here:

http://www.bmj.com/content/333/7568/575

This is the so-called Dubbo study, after the location in which the study was made. It followed patients after Epstein-Barr virus, Q fever, or Ross River virus. Most slowly recovered. Some developed long term issues.

What is not clear is whether those long term patients really have ME or not - we lack biomarkers.

Similar findings have been made with other pathogens, including SARS. Its not the pathogen that is important, though more serious pathogens do tend to be invovled - not the common cold. The Dubbo study concluded that the best predictor of long term non-resolution was severity of the initial infection. Its most probable, from what I understand about immunology, that what they are describing in most cases is a severe immunological response as the best predictor.

In the vast majority of patients post-viral fatigue simply resolves naturally. Due to failures in studies like the Dubbo study, we cannot be sure exactly what the difference is between non-resolvers and actual ME, but for the moment I am presuming there is some correlation. Most doctors know that post-viral fatigue resolves naturally. Its a ubiquitous comment in medical and newspaper articles on the topic. See for example:

http://www.walesonline.co.uk/news/h...s-post-vital-fatigue-syndrome-91466-30636914/

However there are doubts about this story. Take this study on post-SARS:

http://www.mecfs-vic.org.au/sites/www.mecfs-vic.org.au/files/Article-2011Moldofsky-Chronic.pdf

This implies that most patients who show any prolonged response have not recovered out to a year. The exact percentages are not objective enough to be sure, but it looks like only a handful have recovered at one year (only 14% made a full recovery at one year).

However SARS was a very severe infection. If the initial immune response is a major predictor, than any epidemic with major severity will have a higher percentage of long term patients in which post viral fatigue symptoms do not resolve. I strongly suspect that is what ME is.

In post Q fever, maybe 20% of cases do not resolve long term, and at least 1% appear to never resolve. See: http://www.qfever.org/aboutqfever.php

This tells us the data is not very reliable. While my 90% comment is based on two Dubbo studies, the figures may be rubbery. It is also likely to depend on the type and severity of infection. In the common cold, recovery appears to be close to 100%. In SARS it might be very small. In post Q fever its about 80% ... maybe. Vary the criteria, vary the study techniques, and the results vary.

However the general trend is there. Most viral infections see the immunlogical induced symptoms resolve long term. In a subset of cases this appears to involve additional symptoms and do not resolve. In a small percentage there is verifiable viral induced damage, including heart damage, and resolution is difficult to impossible.

There are also a huge range of medically recognized post viral syndromes. See for example Table 1 in:
http://pmj.bmj.com/content/64/753/559.full.pdf

These syndromes are generally not considered psychogenic. They can be postively identified. To me I suspect that strong biomarkers will lead to widespread acceptance of ME.

Another complication is that many docs may confuse mononucleosis and ME. In mono they say most recover in one to two months. Is this the exemplar docs use to encourage patients they all recover in time?

One interesting twist. Here Simon W. talks about post viral fatigue. He starts with neurasthenia, but eventually gets onto a debate on the mind-body dichotomy in explanations. In part he is blaming the medical profession as well for maintenance of false illness beliefs.

http://simonwessely.com/downloads/publications/History/2.pdf

To differentiate between genuine recovery and spontaneous recovery, it is mandatory to have control data. You don't get that in clinical practice. In the studies in which we have controls, like PACE, we do not see such recovery, at least in any data published to date.

Bye, Alex

 

[Valentijn]

Potential misinterpretations aside, the controversy has always been about the accuracy and degree of emphasis placed on the proposed distorted beliefs / unhelpful cognitions and maladaptive behaviours in CFS, not whether such factors could possibly exist at all in any illness. The models underlying CBT and GET present these factors as having major top-down explanatory power for the ongoing symptoms and disability of CFS, while biomedical disease factors are generally missing from these models when it comes to perpetuation.

Wessely has often been somewhat ambiguous about how important these factors are, although obviously important enough to call it the "cognitive behavioural model of CFS" (with its "vicious circle of fatigue"), write dozens of papers on it, and previously claim that after therapy about 1/3 recover and a further 1/3 are helped substantially (without giving control figures of course). Similar claims have been made by other proponents. However, the PACE Trial, the largest RCT on CBT/GET, demonstrated that only about 1/7 or 1/8 report subjective improvements due to these therapies, while those improvements on average are rather modest and may simply reflect palliation rather than rehabilitation

IIRC, Wessely once confessed that he overestimated the association between CFS and depression. A similar confession should be forthcoming for the role of cognitive behavioural factors in CFS. I would respect him more if he did so. An acknowledgment that the nature of improvements is uncertain would also be helpful.

I've been reading his old papers to look for fun (and accurate) quotes and it's been pretty enlightening. In the early years (88-90 thus far) he was basically equating "the CFS" with atypical depression. And of course, he presented many papers "proving" it using the same tactics he's used ever since. I find his diagnosis of depression in ME patients to be quite amusing - basically having ME symptoms proves we have depression! And the CFS patients who refused to recover were generally labeled as the most resistant to having their depression treated. He even advocates for a CFS definition with the primary criteria of fatigue and mood disorders.

Then he latches onto the similarities between historic neurasthenia and ME, and it looked like that's where he picked up the GET theories for treatment. Of course, he assumes that the similarities mean that both diseases are psychiatric Even in the early days (1989) he was asserting that we shouldn't see specialists or go to the hospital unless our mental health therapist agrees, and it is "reasonable to expect a patient to cooperate with treatment before being labelled as chronically disabled" for the purpose of sickness benefits. Seems to rather contradict his statements about it not being bio versus psycho, and that all doctors should work together.

He's been advocating for CBT since at least 1989, when he was still firmly in the depression camp. So even when he changes his theory slightly about causation, he's still working backwards from a starting point of "CBT is the cure" and looking for a way to create a model of illness that supports that. Unfortunately, this is more a matter of warping perceptions of reality than actual science - instead of observing what is happening, and drawing conclusions, he's trying to frame what's happening in a manner that supports his pre-existing beliefs. So we end up with a lot of weird results, like diagnosing all ME patients with depression based on their physical ME symptoms.

 

[Simon]

If Wessely were to say 'I think that it is wrong to treat patients with CFS as if dysfunctional cognitions and the behaviours they lead to are the most significant cause of ongoing disability' that would be significant. So far he's not said anything close to that.

Well, yes, that would be nice, but seems to set the bar for significant change at the Damascene conversion level - wheras I take the view that significant change in his views can occur below that threshold.

I just don't see anything in these letters which is a clear and significant change from what he's said elsewhere.

I think you are probably more familiar with Wessely's writing than just about anyone, so could you point to where he has previously stated:

• Only a minority 'recover' from CFSwith CBT/GET
• In that minority, the original/underlying factors have already resolved and in their case the illness is perpetuated by secondary factors (seems to me he's always previously implied this applies to everyone)

I've read a lot of amibiguous material from Simon Wessely over the last 16 years and don't recall anything like that myself (although my memory is pretty duff). That's why I think his latest letter is significant.

One swallow doesn't make a summer, and the only sure sign that Simon Wessely is changing his views would be a consistent series of statements from him about the limited role for CBT/GET in CFS. I'll be very interested to see what comes out of any further contact between The Countess and Wessely.

 

[SilverbladeTE]

SImon
simple, *unequivcal apology*, admission ME is phsyical illness and that he has been WRONG, would do a world of good from him
but he keeps acting like he's hedging his bets, not wanting to be pinned down, to have plenty of ways to weasel out
again, that may just be because of poor delivery on his part rather than intent of course.

 

[In Vitro Infidelium]

I think you are right that this is a significant change in the 'sales pitch', in line with the results of PACE but not the spin placed on it by most of the authors. ................................

.......................I started off thinking this correspondence was a completely pointless exercise, but I now think it represents an opportunity that at this stage should be judged on its merits, not merely on the Simon Wessely's track record. There isn't going to be a 'Road to Damascus' conversion from Wessely and colleagues. If a genuine change ever came, it would probably start like this. That, of course, doesn't make this a genuine change, but I don't see what we have to lose by exploring the possibility.

'Sales Pitch' is probably the right interpretation. Wessely's career progression may be as much informing his perspective of CFS as any actual change in clinical judgement. As Vice of Dean of Academic Psychiatry his concerns are focussed on the broad role of psychiatry in medicine as a whole, and upon the very practical issue of attracting students into the specialism. All specialisms are in effect competing for resources - teaching,training and service delivery etc, with every other specialism and (at least within the NHS) psychiatry's latest attempt at achieving a USP is the formalisation of Liaison Psychiatry.

I'm actually surprised how 'generous' Wessely has been in responding to Mar given the inauspicious start she gave the exchange, whittering on about who paid for lunch twenty years ago and repeating some of Hooper's canards. Perhaps Wessely feels that having won some of the moral points (at least in the view of some of his other audiences) this is a useful opportunity to declaw the more vociferous opposition to CBT/GET and potentially detoxify the psychiatry versus M.E/CFS scenario. Liaison Psychiatry is going to be a piggy back provision within many service level contracts in the NHS while in contrast specialist M.E/CFS services are unlikey to get future funding so from both a contract bidding perspective and from the view of promoting psychiatry as a specialism, it makes little sense to have established battle lines (which may put off commissioning bodies) over M.E/CFS. Liaison Psychiatry will pick up M.E/CFS cases by default (no one else wants them) under broadly drawn contracts, without having to go through the hassle of establishing an evidence base on which to construct a service contract bid.

Despite it being what I interpret as a market driven change, and distinctly not 'Damascene' I do think it affords significant opportunities to advance M.E/CFS advocacy. Pragmatically there's a great deal that can be done in response to what is in effect a prima facie acceptance by one of the 'leading experts' in the field, that (current) psychiatric led interventions have only limited relevance to M.E/CFS - which of course then raises the question 'what does have relevance ?' Taking that question forward with politicians and service commissioners is likely to be far more rewarding than any sterile position of 'No Psychiatry'.

IVI

 

[Simon]

'Sales Pitch' is probably the right interpretation. Wessely's career progression may be as much informing his perspective of CFS as any actual change in clinical judgement. As Vice of Dean of Academic Psychiatry his concerns are focussed on the broad role of psychiatry in medicine as a whole...

Despite it being what I interpret as a market driven change, and distinctly not 'Damascene' I do think it affords significant opportunities to advance M.E/CFS advocacy. Pragmatically there's a great deal that can be done in response to what is in effect a prima facie acceptance by one of the 'leading experts' in the field...
IVI

Interestinig perspective on what might be behind Simon Wessely's apparent shift in position.He is a very shrewd operator.

 

[Marco]

Pragmatically there's a great deal that can be done in response to what is in effect a prima facie acceptance by one of the 'leading experts' in the field, that (current) psychiatric led interventions have only limited relevance to M.E/CFS - which of course then raises the question 'what does have relevance ?' Taking that question forward with politicians and service commissioners is likely to be far more rewarding than any sterile position of 'No Psychiatry'.

IVI

While the latter 'no psychiatry' view may be held by a minority, to apply it to all patients or advocates is another 'straw man' that continually pops up alongside 'fear of the stigma of mental illness' etc.

There are many strands to psychiatry few of which nowadays are concerned with 'theories of the mind'.

If ME/CFS is as many would contend primarily a neurological illness then it may be a structural, functional problem or both. If purely functional it could well be that psychiatry is the appropriate branch of medicine to treat it.

Not a problem for me. As long as i don't have to endure 'therapies' aimed at changing my 'illness beliefs'.

 

[Esther12]

I think you are probably more familiar with Wessely's writing than just about anyone, so could you point to where he has previously stated:

• Only a minority 'recover' from CFSwith CBT/GET
• In that minority, the original/underlying factors have already resolved and in their case the illness is perpetuated by secondary factors (seems to me he's always previously implied this applies to everyone)

I've read a lot of amibiguous material from Simon Wessely over the last 16 years and don't recall anything like that myself (although my memory is pretty duff). That's why I think his latest letter is significant.

I don't want to pretend to be some expert on Wessely (what a depressing thing to be), I've still got a lot of Wessely stuff I've not read, and I feel it took me a while to get used to how he was using language so probably would benefit from re-reading plenty too... but:

Given the available evidence, claiming that the majority of patients with CFS 'recover' (in any meaningful way) following CBT/GET is just impossible. Anyway, I don't think I've ever seen him explicitly claim that the majority of patients do 'recover' following CBT/GET: he's generally more interested in promoting positive cognitions about recovery and control over symptoms than making specific claims about stubborn reality. Also - he didn't use the term 'recover', and 'symptom free', for a symptom like fatigue, is almost meaningless. Other proponents of psychosocial interventions (not just for CFS) are also trying to play with what 'recovery' means, and downplay the importance of 'symptoms' (which they seem to be rather crap at actually helping with), and it seems to me that this is a rather sly way of getting more funding, and competing with genuinely effective treatments. Also, he doesn't say that a minority of patients are 'symptom free' following CBT/GET, and instead he talks about a 'resolution of the illness': we do not know exactly what he meant be either of these terms, and there is room for weaselling with both.

I really think it's important to quote Wessely accurately, because he often implies things which he does not say.

re the second point: Couldn't that simply refer to triggering and perpetuating factors? He does not say that those who do not recover have an illness that is still being perpetuated by the 'original factor' (whatever that means); it could well be that he believes the disability of all patients is a result of the 'secondary handicaps of chronic illness', but only a minority are committed enough to overcoming them. (I'm not saying that he believes this either, just that his statements do not let us say either way).

'Sales Pitch' is probably the right interpretation. Wessely's career progression may be as much informing his perspective of CFS as any actual change in clinical judgement. As Vice of Dean of Academic Psychiatry his concerns are focussed on the broad role of psychiatry in medicine as a whole, and upon the very practical issue of attracting students into the specialism. All specialisms are in effect competing for resources - teaching,training and service delivery etc, with every other specialism and (at least within the NHS) psychiatry's latest attempt at achieving a USP is the formalisation of Liaison Psychiatry.

I think this is a good point too, and could partially explain some of the recent media coverage as well. The NHS cutbacks could also encourage more of an 'all in it together' mentality too, rather than a critical examination of the claims being made about efficacy from PACE.

Lets remember, Wessely seems pretty keen to speak out about CFS: anyone see him criticise the bullshit claims about recovery being made following the manipulation of PACE's results? I just don't see that him now acknowledging that the majority of patients are not 'symptom free' following CBT/GET is indicative of any change in his approach to CFS.