Neurological Evidence of So-called 'Somatoform' Disorders? (ie FM, IBS, CFS)

Cort

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Sharpe is a behaviorist who was involved in CFS for quite a while but who concentrates for on cancer fatigue now. He places CFS in the 'somatoform disorders' category along with FM, IBS, etc.

Here they are asking whether there is evidence of neural dysfunction in these disorders and the answer appears to be a qualified yes. As always seems to be the case more and better research needs to be done- but its an intriguing look at the neurological basis of these disorders.

Interestingly it focused on the limbic system, which, if memory serves right, Cheney suggested was important early on. What does the Limbic system do? It regulates two systems that are involved in CFS; the endocrine system and the autonomic nervous system.

It appears to be tied to flight/fight response
Paul D. MacLean, as part of his triune brain theory, hypothesized that the limbic system is older than other parts of the brain, and that it developed to manage fight or flight circuitry which is an evolutionary necessity for reptiles as well as humans. However, recent studies of the limbic system of tetrapods have challenged some long-held tenets of forebrain evolution.
This is a large rather, poorly defined system containing these structures

  • Amygdala:[4][5][6] Involved in signaling the cortex of motivationally significant stimuli such as those related to reward and fear in addition to social functions such as mating.
  • Hippocampus:[4][5][6] Required for the formation of long-term memories and implicated in maintenance of cognitive maps for navigation.
  • Parahippocampal gyrus:[5] Plays a role in the formation of spatial memory
  • Cingulate gyrus:[4][5][6] Autonomic functions regulating heart rate, blood pressure and cognitive and attentional processing
  • Fornix:[4][6] carries signals from the hippocampus to the mammillary bodies and septal nuclei.
  • Hypothalamus:[4][6] Regulates the autonomic nervous system via hormone production and release. Affects and regulates blood pressure, heart rate, hunger, thirst, sexual arousal, and the sleep/wake cycle
  • Thalamus:[4][6] The "relay station" to the cerebral cortex.

Psychosom Med. 2011 Jan 7. [Epub ahead of print]

Can Neuroimaging Help Us to Understand and Classify Somatoform Disorders? A Systematic and Critical Review.
Browning M, Fletcher P, Sharpe M.

Department of Psychiatry (M.B.), University of Oxford, Warneford Hospital, Oxford, United Kingdom; Department of Psychiatry (P.F.), University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom; and Psychological Medicine Research (M.S.), University of Edinburgh, Royal Edinburgh Hospital, Edinburgh, United Kingdom.

Abstract
Objective: Debate about the nature of somatoform disorders and their current diagnostic classification has been stimulated by the anticipation of new editions of Diagnostic and Statistical Manual of Mental Disorders and International Statistical Classification of Diseases and Related Health Problems diagnostic classifications.

In the current paper, we review systematically the literature on the neuroimaging of somatoform disorders and related conditions with the aim of addressing two specific questions: Is there evidence of altered neural function or structure that is specifically associated with somatoform disorders?

What conclusions can we draw from these findings about the etiology of somatoform disorders? Methods: Studies reporting neuroimaging findings in patients with a somatoform disorder or a functional somatic syndrome (such as fibromyalgia) were found using Pubmed, PsycINFO, and EMBASE database searches. Reported structural and functional neuroimaging findings were then extracted to form a narrative review.

Results: A relatively mature literature on symptoms of pain and less developed literatures on conversion and fatigue symptoms were identified. The available evidence indicates that, when compared with nonclinical groups, somatoform diagnoses are associated with increased activity of limbic regions in response to painful stimuli and a generalized decrease in gray matter density; however, methodological considerations restrict the interpretation of these findings.

Conclusions: Whereas the neuroimaging literature has provided evidence about the possible mechanisms underlying somatoform disorders, this is not yet sufficient to provide a basis for classification. By adopting a wider variety of experimental designs and a more dynamic approach to diagnosis, there is every reason to be hopeful that neuroimaging data will play a significant role in future taxonomies.E]
 

Cort

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More on the Limbic System

A rather simple look at the limbic system focusing more on emotions but notice the other things involved...temperature regulation, blood pressure, breathing,,

The Emotional Nervous System

Dr. C. George Boeree

Emotion involves the entire nervous system, of course. But there are two parts of the nervous system that are especially significant: The limbic system and the autonomic nervous system.

The Limbic System

The limbic system is a complex set of structures that lies on both sides of the thalamus, just under the cerebrum. It includes the hypothalamus, the hippocampus, the amygdala, and several other nearby areas. It appears to be primarily responsible for our emotional life, and has a lot to do with the formation of memories. In this drawing, you are looking at the brain cut in half, but with the brain stem intact. The part of the limbic system shown is that which is along the left side of the thalamus (hippocampus and amygdala) and just under the front of the thalamus (hypothalamus):

Hypothalamus

The hypothalamus is a small part of the brain located just below the thalamus on both sides of the third ventricle. (The ventricles are areas within the cerebrum that are filled with cerebrospinal fluid, and connect to the fluid in the spine.) It sits just inside the two tracts of the optic nerve, and just above (and intimately connected with) the pituitary gland.

The hypothalamus is one of the busiest parts of the brain, and is mainly concerned with homeostasis. Homeostasis is the process of returning something to some set point. It works like a thermostat: When your room gets too cold, the thermostat conveys that information to the furnace and turns it on. As your room warms up and the temperature gets beyond a certain point, it sends a signal that tells the furnace to turn off.

The hypothalamus is responsible for regulating your hunger, thirst, response to pain, levels of pleasure, sexual satisfaction, anger and aggressive behavior, and more. It also regulates the functioning of the autonomic nervous system (see below), which in turn means it regulates things like pulse, blood pressure, breathing, and arousal in response to emotional circumstances.

The hypothalamus receives inputs from a number of sources. From the vagus nerve, it gets information about blood pressure and the distension of the gut (that is, how full your stomach is). From the reticular formation in the brainstem, it gets information about skin temperature. From the optic nerve, it gets information about light and darkness. (Light sensitivity, stimulus overload?)

From unusual neurons lining the ventricles, it gets information about the contents of the cerebrospinal fluid, including toxins that lead to vomiting. (MCS?) And from the other parts of the limbic system and the olfactory (smell) nerves, it gets information that helps regulate eating and sexuality. The hypothalamus also has some receptors of its own, that provide information about ion balance and temperature of the blood.

In one of the more recent discoveries, it seems that there is a protein called leptin which is released by fat cells when we overeat. The hypothalamus apparently senses the levels of leptin in the bloodstream and responds by decreasing appetite. It would seem that some people have a mutation in a gene which produces leptin, and their bodies cant tell the hypothalamus that they have had enough to eat. However, many overweight people do not have this mutation, so there is still a lot of research to do!

The hypothalamus sends instructions to the rest of the body in two ways. The first is to the autonomic nervous system. This allows the hypothalamus to have ultimate control of things like blood pressure, heartrate, breathing, digestion, sweating, and all the sympathetic and parasympathetic functions.

The other way the hypothalamus controls things is via the pituitary gland. It is neurally and chemically connected to the pituitary, which in turn pumps hormones called releasing factors into the bloodstream. As you know, the pituitary is the so-called master gland, and these hormones are vitally important in regulating growth and metabolism.

Hippocampus

The hippocampus consists of two horns that curve back from the amygdala. It appears to be very important in converting things that are in your mind at the moment (in short-term memory) into things that you will remember for the long run (long-term memory). If the hippocampus is damaged, a person cannot build new memories, and lives instead in a strange world where everything they experience just fades away, even while older memories from the time before the damage are untouched! This very unfortunate situation is fairly accurately portrayed in the wonderful movie Memento, as well as in a more light-hearted movie, 50 First Dates. But there is nothing light-hearted about it: Most people who suffer from this kind of brain damage end up institutionalized.

The amygdalas are two almond-shaped masses of neurons on either side of the thalamus at the lower end of the hippocampus. When it is stimulated electrically, animals respond with aggression. And if the amygdala is removed, animals get very tame and no longer respond to things that would have caused rage before. But there is more to it than just anger: When removed, animals also become indifferent to stimuli that would have otherwise have caused fear and even sexual responses.

Related areas

Besides the hypothalamus, hippocampus, and amygdala, there are other areas in the structures near to the limbic system that are intimately connected to it:

The cingulate gyrus is the part of the cerebrum that lies closest to the limbic system, just above the corpus collosum. It provides a pathway from the thalamus to the hippocampus, seems to be responsible for focusing attention on emotionally significant events, and for associating memories to smells and to pain.

The ventral tegmental area of the brain stem (just below the thalamus) consists of dopamine pathways that seem to be responsible for pleasure. People with damage here tend to have difficulty getting pleasure in life, and often turn to alcohol, drugs, sweets, and gambling.

The basal ganglia (including the caudate nucleus, the putamen, the globus pallidus, and the substantia nigra) lie over and to the sides of the limbic system, and are tightly connected with the cortex above them. They are responsible for repetitive behaviors, reward experiences, and focusing attention. If you are interested in learning more about the basal ganglia, click here.

The prefrontal cortex, which is the part of the frontal lobe which lies in front of the motor area, is also closely linked to the limbic system. Besides apparently being involved in thinking about the future, making plans, and taking action, it also appears to be involved in the same dopamine pathways as the ventral tegmental area, and plays a part in pleasure and addiction.

The Autonomic Nervous System

The second part of the nervous system to have a particularly powerful part to play in our emotional life is the autonomic nervous system. The autonomic nervous system is composed of two parts, which function primarily in opposition to each other. The first is the sympathetic nervous system, which starts in the spinal cord and travels to a variety of areas of the body. Its function appears to be preparing the body for the kinds of vigorous activities associated with fight or flight, that is, with running from danger or with preparing for violence.

Activation of the sympathetic nervous system has the following effects:

  • dilates the pupils
  • opens the eyelids
  • stimulates the sweat glands
  • dilates the blood vessels in large muscles
  • constricts the blood vessels in the rest of the body
  • increases the heart rate
  • opens up the bronchial tubes of the lungs
  • inhibits the secretions in the digestive system

One of its most important effects is causing the adrenal glands (which sit on top of the kidneys) to release epinephrine (aka adrenalin) into the blood stream. Epinephrine is a powerful hormone that causes various parts of the body to respond in much the same way as the sympathetic nervous system. Being in the blood stream, it takes a bit longer to stop its effects. This is why, when you get upset, it sometimes takes a while before you can calm yourself down again!

(Epinephrine levels do not appear to be disturbed in ME/CFS)

The sympathetic nervous system also takes in information, mostly concerning pain from internal organs. Because the nerves that carry information about organ pain often travel along the same paths that carry information about pain from more surface areas of the body, the information sometimes get confused. This is called referred pain, and the best known example is the pain some people feel in the left shoulder and arm when they are having a heart attack.

The other part of the autonomic nervous system is called the parasympathetic nervous system. It has its roots in the brainstem and in the spinal cord of the lower back. Its function is to bring the body back from the emergency status that the sympathetic nervous system puts it into.

Some of the details of parasympathetic arousal include...

  • pupil constriction
  • activation of the salivary glands
  • stimulating the secretions of the stomach
  • stimulating the activity of the intestines
  • stimulating secretions in the lungs
  • constricting the bronchial tubes
  • decreasing heart rate

The parasympathetic nervous system also has some sensory abilities: It receives information about blood pressure, levels of carbon dioxide in the blood, and so on.
There is actually one more part of the autonomic nervous system that we don't mention too often: The enteric nervous system. This is a complex of nerves that regulate the activity of the stomach. When you get sick to your stomach or feel butterflies when you get nervous, you can blame the enteric nervous system.
 
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A rather simple look at the limbic system focusing more on emotions but notice the other things involved...temperature regulation, blood pressure, breathing,,
Ok- if there is dysfunction of a somatic system - then it's not actually 'somatoform', even according to Sharpe himself.

The OED defines ‘somatization’ as (in psychiatry) “the production of recurrent and multiple medical symptoms with no discernible organic cause”. No definition is given in the OED for ‘somatoform’, but the prefix ‘somato-’ is defined as relating to the human or animal body. According to Rief and Sharpe, the suffix ‘form’ has:

…frequently been used in psychiatry to describe a state which is close to or which mimics another syndrome or disorder (e.g. schizophreniform). Somatoform hence means like or mimicking a somatic (medical) disorder…” (2004:387)
 
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Here they are asking whether there is evidence of neural dysfunction in these disorders and the answer appears to be a qualified yes. As always seems to be the case more and better research needs to be done- but its an intriguing look at the neurological basis of these disorders.
I'm sceptical about this review. The problem is that neuroimaging tend not to give clear cut results in any area, even with well-defined patients - and CFS patients are not that.

I was recently reading about neuroimaging results for Schizophrenia; I'm pretty sure the studies in this area are are much bigger and better than for CFS etc but they still struggled to find clear cut differences between patients with Schizophrenia and healthy controls. Where there differences were found in particular brain stuctures, certain features were more common in schizophrenic patients, but they could aways find at least some healthy controls with the same neuroimaging results as schizophrenic patients. Of course, with very small sample sizes (which I suspect apply), there's a much better chance of not finding an overlap between controls and patients.

somatoform diagnoses are associated with increased activity of limbic regions in response to painful stimuli and a generalized decrease in gray matter density; however, methodological considerations restrict the interpretation of these findings.
I suspect this is a gross understatement.
 

Cort

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I'm trying to get the paper. It's amazing how many papers have methodological problems....I'm beginning to think that its probably the majority of them.

Where there differences were found in particular brain stuctures, certain features were more common in schizophrenic patients, but they could aways find at least some healthy controls with the same neuroimaging results as schizophrenic patients.
As I remember this was a big problem with MRI's and CFS; those white punctated areas were more commonly found in CFS but were also found in some healthy people.....
 

SilverbladeTE

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yeah, they interpret them with the damn cart before the horse!
ye GODS, the hubris of these people. :headache:

the disease causes these changes, not "thinking you have a disease"

note:
any of you had meningitis or similar disease that causes over stimulation of the nervous system? I have.
note the similarities with ME/CFS symptoms, in that, bright light, loud noise etc all cause pain etc etc?

some aspect of ME/CFS is causing assualt, inflammation or such on the nervous system, hence the original bloody name for it
myalgic encephalomyelitis (oh jeez can't spell it now, lol)
encephalomyelitis (or however ya spell it, damn it, fragnabbit blasted illness,lol) inflamation and thus damage of the brain/nervous system

from all the few autopsies that have been done, and the far FAR too few brain scans, and other such, Me/CFS is a neuralogical illness like syphilis, Lyme Disease and several other such, but Lyme's the closest in many effects.
Does anyone say "Oh my, you think you are sick with Lyme, but your all grumpy and suicidal it's all jsut because you are making yourself really sick!"
(well actually they did...but that's another story we're all used to)

absolute BALDERDASH! CADSWALLOP! and I'm using polite terminology ;)

these people will see what they wish to see, they only see this disease as psychological, so twist the facts to suit their own "mad as a hatter" pie-in-the-sky garbage that should have died 70 years ago. Grrr.

Now, having said that, or ranted a bit ;)
I can suggest this:
yes, mood does affect ME/CFS
like it does with many other illnesses. but it does not CAUSE it. ME/CFS though, reacts especially strongly to stressors, much beyond the norms, hence these findings.
they are putting THEIR crazy belief system onto the useful facts, here.

now as most of us know, relaxing music, warm bath etc, all help with this illness, and, conversely, stressors make it worse, note STRESSOSRS, not just psycholigical stress.

So, this disease or complex syndrome in reaction to a disease, obviously has a tight interplay with how the body percieves stress.
and you know what? that's how the body deals with infections anyway!

I'd bet good money a lot of the symptoms of ME are caused by the body's immune response to a disease it believes is beyond the blood/brain barrier it cannot reach to fight, including the peculiar horomonal (pituitary) and temperature (hyopthalmus) issues.

the body is seeingly trying ot keep us hot (heat intolerances, most commonly ME folk run slight temperatures) and horizontal (blood pressure/heart, POTS)
all symptoms of the body reacting to a persistant infection: burning it off, trying to keep us quiet as possible.

the worst infection of them all though, is "hubris" that quackery that seems to have infested Psychiatry! :rolleyes:
 

biophile

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Don't celebrate just yet

Cort says: Here they are asking whether there is evidence of neural dysfunction in these disorders and the answer appears to be a qualified yes. As always seems to be the case more and better research needs to be done- but its an intriguing look at the neurological basis of these disorders.
The core finding is "increased activity of limbic regions in response to painful stimuli and a generalized decrease in gray matter density". Biological does not automatically mean organic, so without knowing the direction of causation, these neural correlates just mean is that there is evidence these symptoms are "real" in the sense we actually experience them. If mental processes are reduced to or at least intimately related to physical processes, this should be expected from many serious mental disorders as well, even with the current limited technology.

Remember the recent discussion on this forum about the questionable value of neuropeptide-Y as a biomarker? I notice a debate is also going on at the other forum about the value of CFS research into immune response to exercise, as a similar response or components of the CFS response may be observed in mental disorders as well. Judging from the abstract, the results of Sharpe's neuroimaging review is sort of like that. In fact, many of the biological abnormalities in CFS are in the same boat, some of course suggest organic disease but people will continue to argue they could be "functional" or psychiatric or psycho>somatic with the increased activity of the limbic regions taken as biological evidence that CFS is an emotional disorder.

Angela Kennedy says: Ok- if there is dysfunction of a somatic system - then it's not actually 'somatoform', even according to Sharpe himself. [...] "somatoform hence means like or mimicking a somatic (medical) disorder".
Good point but not necessarily, Sharpe probably sees this "dysfunction" as functional without proven organic medical cause ie somatoform, perpetuated primarily by psychological and lifestyle/behavioural factors.

It has been argued that the symptoms of so-called functional somatic syndromes as well as the supposed enhanced interoception experienced in somatisation and neuroticism is due to a misinterpretation or hypervigilant appraisal of ordinary signals reaching the brain, which is usually implied as a psychogenic explanation with the assumption that nothing else biological is going wrong in the process along the way.

Sharpe has argued before that this is the "extreme psychogenic view" of CFS and insists we should have a biopsychosocial perspective instead. However, biopsychosocialists can use "etiologically neutral" findings of increased neural activity and reduced grey matter volume to argue for a biological but functional/non-organic version of psychological amplification as one component of CFS, while avoiding the appearance of claiming pure psychogenesis but continuing the emphasis on a primary role for abnormal illness beliefs and deconditioning.

As SilverbladeTE points out, the similarities to organic disease and the biological factors are underestimated.
 
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With regard to Sharpe, if something is happening at the level of the body, then it is, technically speaking, somatic. I would argue that the term 'somatoform' is an incorrect term full stop, and that Sharpe is getting himself confused in his deliberations of 'mind/body'.

One problem is Sharpe's (and others') attempts to claim primacy of metaphysical phenomena (beliefs, lies, delusions) over somatic phenomena, a 'mind over matter' causation explanation (if you like! sounds like 'Dalmation plantation'- apologies for over -alliteration there) based merely on uncertainty in medical knowledge of biological processes (the premature and fallacious concept of 'medically unexplained') . As is clear from his co-authored article, actual physiological evidence to support 'neurological evidence' of the so-called 'somatoform disorders' are circumstantial at best; can always be explained alternatively (banal and common effects of neuroplasticity, impact of physiological dysfunctions, impact of distress from being ill- let alone accompanying psychogenic dismissal- for example); aren't supported even by reasonably strong correlations; and are based on the fallacy of 'medically unexplained'.

This means Sharpe and pals have designated people as 'somatoform' by default. All of that group could have underlying, undetected but diverse organic illnesses for all we (or they) know. It would be like designating people 'possessed by demons' and then using any recurring physiological phenomenon as evidence of 'demonic possession'.

Sharpe is interesting because he has been, by the looks of it, trying to avoid 'pure psychgenesis' (if you like) explanations, but he's resorting to mind over matter explanations that cannot be tested, and which fall down even logically.

Solvason et al related a case of a woman who, diagnosed with psychogenic illness on the basis of difficulty in explaining her symptoms, and her distress at her family‘s response to her being lesbian, choked to death in hospital while staff presumed her choking was psychogenic. An abnormal EEG taken earlier was not scrutinised until after her fatal choking episode had rendered her unconscious. Post-mortem, she was found to have Creuztfeldt-Jacob disease. Solvason et al actually claim that their patient “communicated her distress through an elaboration of symptoms”, and that her “illness behaviour” and “lack of evidence of a medical or neurologic illness” contributed to a “confusing clinical picture”. Sharpe, however, with his colleague Stone, in their reply to Solvason, defended psychogenic diagnoses by saying:

“Failure to make a positive diagnosis of conversion disorder can have serious adverse consequences. The patient may be denied appropriate treatment management that vitally depends on persuading him or her that the symptoms are reversible and not due to disease…”
By their logic, even though a psychogenic explanation cannot be tested or empirically verified; even though the patient died because others wrongly believed her choking was psychogenic; even though her illness was eventually confirmed as organic; even though it is also impossible at this to rationally test or empirically verify exactly which somatic symptoms are 'psychogenic' in cases of organic illness; patients still need prompt diagnoses of ‘conversion disorder’ and to be persuaded their illness is not organic, even when organic disease might be present.

In another paper, Stone and Sharpe and colleagues contradict their earlier positions by admitting this:

“…belief about the conversion of emotional distress into physical symptoms, which despite the lack of evidence for them are widely held.” (Stone et al, 2006: 208)
This is a striking claim by them, because the key premise of a diagnosis of ‘conversion disorder’ is the ‘conversion’ of psychological conflict or ‘stressors’ into physical ‘symptoms‘ (see DSM-IV). There is no other context in which the word ‘conversion‘ is used in this diagnosis.

So it looks like the old 'mind-body' dualism is more difficult to conceptually get around than authors like these claim, and Sharpe and colleagues are struggling with their 'psychogenic' positions intellectually. The old 'we're not pure or extreme psychogenic proponents' is something of a cop-out here- precisely because it is currently SO difficult (often impossible) to accurately, or even plausibly, tease out psychogenic versus organic phenomena.

If anyone wants the above references, let me know.
 
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I would also say Sharpe et al's 'we're not pure or extreme psychogenic proponents' functions as something of a straw man. He's not like those unreasonable (but likely mythical) meanies/sillies who believe in 'only' psychogenic explanations.
 

IamME

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"Dysfunction" is not the same as "disease", it just means something is not working properly. The brains of people with most "mental" illnesses won't be "working properly", but that doesn't mean there's an unequivocally organic cause (as opposed to a "vicious cycle" or "complex interaction..." or "autopoesis" etc etc). As Biophile says, neuroimaging showing increased activity on stimulus doesn't prove anything except the brain is doing what brains do.

I think you've fallen head first into one of the worst psychologiser's disengenous legerdemains. But then I've heard that PTSD is considered "physical" in the States! Why are you such a soft touch for this sort of dross? FYI Sharpe is still interested in CFS under the aegis of unexplained symptoms and is a proponent of the "biopsychosocial" drivel. He's also one of the ones who (unlike White FWIW) wants to get rid of the WHO "somatisation" classification - so that everything can be a bit somatoform and become a psych finger inviting pie.

In case people aren't aware, Sharpe is one of the trialists of the notorious "PACE" trial. He included CFS in his "ABC's of Psychological Medicine" in the BMJ, co-authored the Oxford and Fukuda definitions and has been an advisor to UNUM provident (see http://www.meactionuk.org.uk/UNUMProvident_Sharpe_and_CBT.htm). He co-authored the 2006 "Occupational Aspects of the Management of Chronic Fatigue Syndrome: A National Guideline", and was one of the condemned NICE guidelines' peer reviewers. His research interests include "both chronic disease related and unexplained by disease, (especially fatigue depression and pain)". This is the type of "neurology" he does.

You can read notorious quotes from him here.

Some examples:

These unhelpful or dysfunctional cognitions include the beliefs that recovery from the illness is not under personal control or that the illness is poorly understood. It has been suggested that dysfunctional cognitions and maladaptive behaviour interact with the physiological factors and psychiatric illness to perpetuate the disability that comprises CFS. Increasing physical deconditioning may lead to helplessness"
the use of extensive laboratory investigation may be psychologically harmful to the patient by reinforcing their beliefs about serious physical disease.
Reports from doctors for employers, insurance companies and benefit agencies could reinforce beliefs and behaviour to delay full recovery
He also wrote a CFS book along with his Stockholm syndrome buddy patient which is to be avoided at all costs (apart from critique).

Please don't misinform people by giving the impression that he's had some kind of a road-to-damascus or has anything useful to contribute to ME/CFIDS.
 

IamME

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Great one Cort - and how these so-called somataforms will have to tumble now.
Did you read what I wrote Enid? Where is the evidence in what Cort posted that Sharpe has ceded psychosomatic illnesses to a neurological "cause"? Are you aware that the psychs (and quacks like LP/MT people) already impute the HPA axis and amygdala (which largely processes fear response cf. "fear avoidance" of CBT) as the "complex interaction" of somatoform or psychosomatic illness. Do you seriously think he's not going to recommend CBT, antidepressants or some other behavioural therapy for them?

Psychiatry relenquishing their illnesses is not going to come from psychiatry (never has), and at any rate I don't understand why people are always fighting on the front of mental illnesses in general when we've got our work cut out with just one misdiagnosis, and it's notable as generally unlike mental illnesses it doesn't even look like a mental illness (the phenomena of it is far more important and precedent than the taxonomy which is an epiphenomenon of accurate description).
 

Dx Revision Watch

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...In case people aren't aware, Sharpe is one of the trialists of the notorious "PACE" trial...

Prof Sharpe is also a member of the APA's DSM-5 Work Group charged with the revision of the DSM-IV categories for "Somatoform Disorders".

Sharpe's bio sketch and disclosures are here:

http://www.dsm5.org/MeetUs/Documents/Somatic/Sharpe - Disclosure - 1-11-10.pdf

He was also the UK Chair of Dr Richard Syke's CISSD Project which published a review, in mid 2007, that fed into the DSM-5 revision process and also into the ICD-11 revision process; the CISSD committee went on to provided four members of the DSM-5 Work Group for "Somatic Symptom Disorders".

Another CISSD committee member, Javier Escobar, went on to became a member of the DSM-5 Task Force and acts as liaison between the Task Force and the SSD Work Group.

On 14 January, the SSD Work Group published revised proposals for the "Somatic Symptom Disorders" which can be read on my site here:

Revisions to DSM-5 proposals on 14.01.11: New category proposed “Simple Somatic Symptom Disorder”: http://wp.me/pKrrB-St

and Phoenix Rising in this thread, here:

DSM-5 proposals revised on 14 January: New category: Simple Somatic Symptom Disorder

http://forums.aboutmecfs.org/showth...gory-Simple-Somatic-Symptom-Disorder&p=151098

Suzy
 

IamME

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Also bear in mind CBT evangelists like Trudy Chalder and the Dutch group have claimed that CBT can repair brain volume loss (presumably a bit like repairing the bodily volume loss of anorexia) which should tell you more about what intrinsic worth "alterations" found on imaging have in this field.

Wessely will also happily tell you about the immunological research he's done -- doesn't mean he's going to retract his "how thinking can make you ill" NS article, de-recommend CBT/GET, recommend antivirals and get out of CFS now, does it?
 

Dx Revision Watch

Suzy Chapman Owner of Dx Revision Watch
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Also bear in mind CBT evangelists like Trudy Chalder and the Dutch group have claimed that CBT can repair brain volume loss (presumably a bit like repairing the bodily volume loss of anorexia) which should tell you more about what intrinsic worth "alterations" found on imaging have in this field....
Ah, yes, it was Chalder's presentation that so impressed the "Gibson Inquiry" panel:

From the "Gibson Report", Page 23,

http://www.erythos.com/gibsonenquiry/Docs/ME_Inquiry_Report.pdf

4.3 Cognitive Behavioural Therapy

The most effective psychological therapy, which has been shown as such in
controlled clinical trials, is Cognitive Behaviour Therapy (CBT). This treatment has
shown to be effective in patients with many long term illnesses for example
cancer. Prof Trudie Chalder presented to the group on this treatment. Prof
Chandler’s [sic] results were impressive. This treatment certainly has a role to play in
treating CFS/ME. Although in other illnesses this treatment is provided as an
adjunct to treatment for the organic disease, in CFS/ME this, and GET (see
below), are the only available treatments which have been shown to be effective
in several controlled trials. It is unfortunately the case that no other treatments
have yet emerged, again emphasising the need for more research.
CBT is most effective in those with less severe forms of CFS/ME and appears to
be much less effective in those with severe disease. As mentioned earlier this has
led to some patient groups, speaking for those with severe disease, to deny that
those with the less severe CFS/ME symptoms are true CFS/ME sufferers. It is
clear however that no matter how successful or unsuccessful CBT may be it is at
best only a partial answer. Prof Chalder suggested that CBT has a biological effect
on the body. The Group would like to see further research into what this effect is
as it may open avenues of investigation into biomedical causes.

Chalder's PowerPoint presentation slides, here: http://www.erythos.com/gibsonenquiry/Docs/Chalder.ppt

And there are people who wondered why I was not prepared to hand a copy of this unofficial report to my MP.
 

Dx Revision Watch

Suzy Chapman Owner of Dx Revision Watch
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...Wessely will also happily tell you about the immunological research he's done -- doesn't mean he's going to retract his "how thinking can make you ill" NS article, de-recommend CBT/GET, recommend antivirals and get out of CFS now, does it?
"We're not going to go doing more and more tests to find out what was the virus because, frankly, even if we found it there's nothing we're going to do about it. We're in the business of rehabilitation."

Extract from BMJ podcast of Dr Esther Crawley and Prof Simon Wessely discussing CFS and ME can be downloaded here. (This is a 14 MB mp3 file.)

http://tinyurl.com/BMJPodcastECSW

"Treatment, very similar in large areas of medicine is about rehabilitation, it’s about, O.K., this has happened to you, you’ve been handed a particular hand of cards. Let’s have a look at how you play it because there are good and bad ways of managing this illness. Now we start to look at all the secondary effects that have happened to you and a lot of people with CFS have got depressed, no question about it, and I don’t mind, you know, that may upset people, but that’s just simply true. We also know that there are a lot of people who've had depression are more at risk of developing CFS. So if people have got depression let’s not ignore it - we’re gonna treat that. Some people got themselves into very unhelpful patterns of activity and you know, their activity management isn’t very good - they do too much, get exhausted then they do too little to recover and that’s not a very satisfactory way. We’re gonna look at sleep hygiene – can we improve sleep? We’re gonna look at pain control were gonna look at this whole balance of rest, activity, sleep, energy and exercise. Were gonna look to make things predictable and so that they’re consistent over a period of time and then we are gradually going to look to steadily increase that over a period of what may well be weeks, more likely many months.

All the time we’re doing this by saying look we don’t really know why you got ill. We don’t know! We’re not going to lie you down on the couch and talk about your mother because it’s entirely irrelevant – we're not going to do more and more tests well what was the virus, because frankly, even if we found it there’s nothing we’re going to do about it. We’re in the business of rehabilitation. It’s an approach that works and it’s an approach that works in many analogous conditions particularly for example chronic pain syndromes that are rather similar. It's about improving control of illness - it’s about improving management – it’s about improving quality of life – improving the control of symptoms and many people, and again I’m quoting studies here, will do very well on this approach."
 

Enid

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I am just walking with countless long term health problems (passed out twice in early days) Whatever the psychos have to say is simply incorrect - we all know that and that this thing called psychiatry and it's odious influence on real science is a diagrace or worse. But we cannot wait for them to catch up with the flood of real doctors and real science now - they are PATHETIC>
 

Dx Revision Watch

Suzy Chapman Owner of Dx Revision Watch
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...This is a striking claim by them, because the key premise of a diagnosis of conversion disorder is the conversion of psychological conflict or stressors into physical symptoms (see DSM-IV). There is no other context in which the word conversion is used in this diagnosis.

So it looks like the old 'mind-body' dualism is more difficult to conceptually get around than authors like these claim, and Sharpe and colleagues are struggling with their 'psychogenic' positions intellectually. The old 'we're not pure or extreme psychogenic proponents' is something of a cop-out here- precisely because it is currently SO difficult (often impossible) to accurately, or even plausibly, tease out psychogenic versus organic phenomena.

If anyone wants the above references, let me know.
The most recent proposals (14 January 2011) by the DSM-5 SSD Work Group for the revsion of the DSM-IV category known as "Conversion disorder" are:

http://www.dsm5.org/Documents/Somatic/Somatic Symptom Disorders description January 14 2011.pdf

V. Functional Neurological Symptoms (previously, Conversion disorder (#300.11)

The essential feature of this disorder is neurological symptoms that are found, after appropriate medical assessment, to be incompatible with a general medical condition. The symptoms include weakness, events resembling epilepsy or syncope, abnormal movements, sensory symptoms (including loss of vision and hearing), or speech and swallowing difficulties. In addition, the diagnosis will usually be supported by evidence of internal inconsistency or incongruity with neurological disease. This evidence may include physical signs (such as, Hoovers sign of functional weakness) or diagnostic investigations (such as seizure-like behaviour in the absence of simultaneous non-convulsive activity on EEG). The symptoms may be acute or chronic. Whilst psychological factors may be noted to be associated with the onset of symptoms, they are not essential for the diagnosis. Co-morbid neurological disease may also be present and does not exclude the diagnosis.

If there is evidence that the symptoms are intentionally feigned, the condition is not conversion disorder but rather either factitious disorder or malingering. When the symptom is limited to pain, fatigue, dizziness, cognitive symptoms or to a disturbance in sexual functioning, it is typically coded elsewhere in the DSM (a different Somatic Symptom Disorder diagnosis or in the Sexual Disorders Section).

[Ed: Previous version of this document (29.01.10) had read (as "III. Conversion disorder"): Patients with conversion disorder typically present with neurological symptoms that are found, after appropriate medical assessment, to be incompatible with a general medical condition. These presentations may be acute or chronic. Typical symptoms include weakness, events resembling epilepsy or syncope, abnormal movements, sensory symptoms, dizziness, speech and swallowing difficulties. In addition, the diagnosis will usually be supported by confirmatory physical signs or diagnostic investigations consistent with the diagnosis (such as, Hoover's sign). Psychological factors may be associated with the onset of symptoms, but are not essential for the diagnosis. If there is evidence that the symptoms are intentionally feigned, the condition is not conversion disorder but rather either factitious disorder or malingering.]

Criteria A, B, C and D must all be fulfilled to make the diagnosis:

A. One or more symptoms of altered voluntary motor, sensory function, cognition, or seizure-like episodes

B. The symptom, after appropriate medical assessment, is not found to be due to a general medical condition, the direct effects of a substance, or a culturally sanctioned behavior or experience.

C. Physical signs or diagnostic findings that provide evidence of internal inconsistency or incongruity with recognized neurological or medical disorder.

[Ed: Previous version of this document (29.01.10) had read: Criteria A, B, and C must all be fulfilled to make the diagnosis: A. One or more symptoms are present that affect voluntary motor or sensory function. B. The symptom, after appropriate medical assessment, is found not to be due to a general medical condition, the direct effects of a substance, or a culturally sanctioned behavior or experience. C. The symptom causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.]

D. The symptom causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

[Ed: Criteria D above is new text.]
 

Esther12

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re: “Failure to make a positive diagnosis of conversion disorder can have serious adverse consequences. The patient may be denied appropriate treatment management that vitally depends on persuading him or her that the symptoms are reversible and not due to disease…”

I think that they fail to realise that treating people with respect, and as if they are able to manage their own lives without interference from the state, will always carry a burden for those who are least able to do so. But there's a general presumption of sanity because to treat people as if they are psychologically disturbed so easily leads to abuses.

There is no way the the general population would be willing to be up with the psycho-social management that CFS patients have had to endure. Maybe they are helping some people, but they seem to think that the only reason they could be harming others is because some people have a particularly unenlightened view of psychological illness, and that otherwise collaborative, caring CBT could only people a helpful thing.

Edit: (PS: That sounds more universally anti-CBT than I really am...)

Also... just saw this on the BBC site about someone who has just had a neurological problem identified after years of pain and fatigue:

http://www.bbc.co.uk/news/health-12182854

"I had almost convinced myself it was psychological," Rhya says frankly. "I saw my GP so often I felt sure she thought I was putting it on."

I don't think they realise the strain that having others treat you as if your are psychologically disturbed despite the absence of good positive evidenc ethat this is the case can have upon patients.
 

Enid

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Look there is a real disease process going on in ME/CFS - it is not yet treated with much respect - (anyone in the know has dispensed with the psychobabblers long ago). Stick to the now global research/findings in real and dedicated researchers (mostly US) - who will find.