What do you make of the following (in bold):
White said:
Doctors have historically tended to diagnose ‘stress’ or ‘psychosomatic disorders’ in people with symptoms that they cannot explain.
History is full of such disorders being reclassified as research clarifies the pathology. An example is writer’s cramp (
p. 1122) which most neurologists now agree is a dystonia rather than a neurosis.
The likelihood is that these functional disorders will be reclassified as their causes and pathophysiology are revealed. Functional brain scans suggest enhancement of brain activity during
interoception in more than one syndrome. Interoception is the perception of internal (visceral) phenomena, such as a rapid heartbeat.
I wanted to make a joke about
wanker's cramp in medical writers, but I did not know how to frame it.
I would not get too excited about White's statement. It is probably a combination of reasonable foresight and
CYA, with a slight hint of mea culpa. White once organized a conference because he was concerned that the biomedical approach was akin to travelling up a
blind alley in medicine's attempt to help patients improve their health and function. I doubt much has changed. White probably thinks that there is more to CFS than the current understanding of functional illness, but I doubt he means that CFS is going to be reclassified as an organic disease. Consider his opening paragraph for context:
White said:
So-called functional (in contrast to ‘organic’) disorders are illnesses in which there is no obvious pathology or anatomical change in an organ and there is a presumed dysfunction of an organ or system. Examples are given in Table 23.8. The psychiatric classification of these disorders would be somatoform disorders, but they do not fit easily within either medical or psychiatric classification systems, since they occupy the borderland between them. This classification also implies a dualistic ‘mind or body’ dichotomy, which is not supported by neuroscience. Since current classifications still support this outmoded understanding, this chapter will address these conditions in this way.
In other papers he states that CFS is a mind-body illness which is both psychological and physical. His reference to neuroscience and his ideas on the involvement of the physical component in CFS are not about organic pathologies, but some form of philosophical physicalism i.e. the mind is a function of the brain and the brain interacts with the rest of the body, while functional non-organic bodily disturbances are also physical in an ontological sense.
Such a grey area is an interesting subject and may in fact exist, but the associated claims and concepts are usually so entangled in spin and questionable research that nothing can be taken at face value. Look at how White continues to claim or allude that an effective treatment for CFS is an increase in activity despite post-exertional symptoms. This is not 20 years ago when the research was relatively new and speculation was more acceptable in the face of the unknown. The evidence is largely already in and as a result we know that the response to exercise is abnormal and is not explained by deconditioning, and that there are no sustained significant increases in total activity levels after so-called "rehabilitative" therapies.
If quackery is defined as the over-promotion of treatment, then perhaps Peter White is guilty of quackery. I do not want to use disparaging terms, but he continues to promote falsehoods which the research does not demonstrate and has been repeatedly shown to be false. Proponents of CBT/GET for CFS seem generally disinterested in getting to the bottom of the nature of the reported improvements. Instead they appear to be happy perpetuating the myths which helped their careers.
The claimed role of cognitive-behavioural factors is generally based on poor or unconvincing and contradictory evidence, with a misunderstanding about certain symptoms (e.g. conflating post-exertional symptomatology with abnormal avoidance behaviours and deconditioning). The associated therapies are based around distorted presumptions about the nature of the illness, and induce only small to moderate subjective improvements in a minority of patients without corresponding objective improvements, which can be explained just as well as the methodological artifact of superficial changes to questionnaire-answering behaviour after given encouragement and optimism about improvements.
How long must it continue until it becomes a form of
pathological science? I think legal action here is unrealistic (taniaaust1), particularly when harm would be difficult to demonstrate in court. Spin and misleading citations seems to be a common problem in academia, so I doubt that White's actions would even raise an eyebrow right now.
I am disillusioned and disheartened by it all. I do not know what the answer is, but I just plod away on analyzing the research when I can, in order to keep myself informed. I started out believing CFS was mostly a mind-body illness and sought evidence for it, but I ended up falling down this rabbit hole and re-assessing my beliefs. The house of cards is going to collapse eventually. The relevant authorities have been sleeping at the wheel, but over the last several years there has been positive signs that awareness is increasing about the dubious quality of science in psychology and psychiatry in general.