from:
"Comparative epidemiology of chronic fatigue syndrome in Brazilian and
British primary care: prevalence and recognition"
Hyong Jin Cho, Paulo Rossi Menezes, Matthew Hotopf, Dinesh Bhugra, and Simon
Wessely
The British Journal of Psychiatry, Feb 2009; 194: 117 - 122
CORRESPONDENCE:
Vasudeo P. Paralikar, Mitchell G. Weiss, Mohan Agashe, and Sanjeev
Sarmukaddam
Diagnosing chronic fatigue syndrome
The British Journal of Psychiatry, Oct 2009; 195: 369.
CORRESPONDENCE:
Hyong Jin Cho, Paulo Rossi Menezes, Matthew Hotopf, Dinesh Bhugra, and Simon
Wessely
Authors' reply:
The British Journal of Psychiatry, Oct 2009; 195: 369 - 370.
---
I do not have access to these letters at this moment in time but I presume
they are similar to the e-letters on their website.
In the letter, the authors challenge the validity of CFS:
"Accepting that premise, however, requires that we ignore the fact that CFS
is neither in the ICD or DSM, and neurasthenia was rejected after
consideration in the draft version of DSM- IV (Paralikar et al., 2007).
Standard texts in the field of cultural psychiatry regard CFS as a North
American culture-bound syndrome (Griffith et al., 2003)."
(I also have a quick comment on the site pointing out that the authors never
adjusted the prevalence rates despite the fact that the participants in
Brazil and the UK were 79.7% and 71.5% female respectively, a pretty basic
error if one is going to quote prevalence rates!!).
Tom
http://bjp.rcpsych.org/cgi/eletters/194/2/117
Diagnosing CFS: Cross cultural studies are necessary to avoid category
fallacy 19 March 2009
Vasudeo P Paralikar,
Consultant Psychiatrist
KEM Hospital, Rasta Peth, Pune, India,
Mitchell G Weiss, Mohan Agashe, Sanjeev Sarmukaddam
In their comparative epidemiological study of CFS in Brazil and London, Cho
and colleagues (2009) conclude that cultural differences affect only the
recognition, rather than occurrence, of this condition. Although a
reasonable interpretation of the epidemiological data, without complementary
consideration of the cultural context, the assertion is likely to obscure
some of the most salient features and clinical significance of the study.
The authors note that "both population and healthcare professionals seem
unfamiliar with the construct of the syndrome." Recognition of the community
and professional inattention and low priority for CFS, however, is not
necessarily a failing; it may also be regarded as an updated example of
Kleinman's formulation of the category fallacy—the imposition of alien
diagnostic concepts where they lack local validity. The assertion of
under-recognition is incomplete without consideration of alternative
formulations of the problems that in some respects resemble, but are not
diagnosed, CFS. Do such conditions, such as neurasthenia in East Asia and
dhat syndrome in South Asia, have characteristic patterning of distress or
meaning in Brazil?
If one accepts the authors' tacit premise that the construction of CFS and
related UK formulations (Encephalomyelitis and fibromyalgia) are
unquestionably valid diagnoses for use everywhere, then the conclusion that
CFS is neglected by professionals but no less important in the Brazilian
population is valid. Accepting that premise, however, requires that we
ignore the fact that CFS is neither in the ICD or DSM, and neurasthenia was
rejected after consideration in the draft version of DSM- IV (Paralikar et
al., 2007). Standard texts in the field of cultural psychiatry regard CFS as
a North American culture-bound syndrome (Griffith et al., 2003). Earlier
research by some of the same Brazilian authors also highlights the social
determinants of essential features of chronic fatigue, rather than the
categorical diagnosis of CFS (de Fatima Marinho de Souza et al., 2002).
Culturally sensitive clinical care will benefit from reconsideration of a
cultural interpretations of these study data and from additional
cross-cultural research. Are other diagnoses or local clinical and cultural
formulations used to manage and treat such patients locally? Are other
non-medical sources of help and social interventions given higher priority
by patients and communities in Brazil? Findings of Karasz and McKinley
(2007) showing the tendency of North Americans to 'medicalize', and South
Asians to 'socialize' similar clinical vignettes recommend consideration of
that point. Among patients studied by Cho et al., one might also ask whether
higher rates of associated common mental disorders suggest these psychiatric
conditions are more likely to be the focus of treatment. The emphasis on
under-recognition of CFS is likely to prove less important for community
mental health and culturally sensitive care than questions of how such
clinical patterns are understood in the population and explained by
professionals.
References
Cho HJ, Menezes PR, Hotopf M, Bhugra D, Wessely S. (2009). Comparative
epidemiology of chronic fatigue syndrome in Brazilian and British primary
care: prevalence and recognition. The British Journal of Psychiatry 194,
117–122. doi: 10.1192/bjp.bp.108.051813
Kleinman, A. (1977). Depression, somatization, and the new cross- cultural
psychiatry. Social Science & Medicine, 11, 3-10.
Paralikar V, Sarmukaddam S, Agashe M, Weiss, MG. (2007). Diagnostic
concordance of neurasthenia spectrum disorders in Pune, India. Soc
Psychiatry Psychiatr Epidemiol, 42, 561-572.
Griffith EE, Gonzalez CA, & Blue HC. (2003). Introduction to Cultural
Psychiatry in Textbook of Clinical Psychiatry, Eds Hales, R., & Yudofsky, S.
4th Edition, Vol.2, 1551-1583. American Psychiatric Publishing, Washington
DC, London UK.
de Souza M de Fatima Marinho, Messing K, Menezes PR, & Cho HJ. (2002).
Chronic fatigue among bank workers in Brazil, Occupational Medicine
52:187-194
Karasz A, & McKinley PS. (2007). Cultural Differences in Conceptual Models
of Everyday Fatigue-A vignette study. Journal of Health Psychology, 12(4),
613-626.
=============
Re: Diagnosing CFS: Cross cultural studies are necessary to avoid category
fallacy
15 July 2009
Hyong Jin Cho,
Research fellow
Department of Psychiatry, Federal University of São Paulo, Brazil,
Paulo Rossi Menezes, Matthew Hotopf, Dinesh Bhugra, and Simon Wessely
We thank Dr Paralikar and colleagues for their interests in our recent
article. The assertion that chronic fatigue syndrome (CFS) is a
culture-bound syndrome of the high-income Western countries may be largely
based on the observation that "clinical descriptions of chronic fatigue
syndrome, also known in some countries as myalgic encephalomyelitis, have
arisen from a limited number of high-income countries in Northern Europe,
North America and Oceania" (quote from Cho et al, 2009[1]). We aimed to
examine the reasons for this particular observation while proving or
disproving the above assertion was beyond the scope of our study. Without
any pre-assumptions regarding the local validity of the construct of CFS, we
used this 'etic' construct originated from the high-income Western countries
in Brazil in order to examine whether this foreign concept defines a similar
proportion of individuals as cases. We found that, using the current CDC
case definition of CFS, similar proportions of primary care attenders were
defined as CFS cases in Sao Paulo and London. However, Brazilian doctors
were unlikely to recognise and/or label such patients as CFS cases.
In a way, we actually used Kleinman's formulation of the category fallacy as
a research method in our study. That is, by imposing an alien diagnostic
concept where its local validity is untested and unknown, we examined which
component of this alien construct is not sanctioned by the local cultural
context: the occurrence itself or the recognition/labelling. In Brazil,
although unexplained fatigue as formulated by the Western medical community
indeed does occur, "it is not sanctioned as a medical condition worthy of
medical treatment, sick leave or sickness benefit, and it may be more likely
to be considered as part of everyday adversity and less likely to be
recognised as a medical disorder" (quote from Cho et al, 2009[1]).
Furthermore, while Paralikar et al suggested our paper lacked the
consideration of the cultural context, we actually discussed and interpreted
these findings mostly in light of the sociocultural context. For example,
based on the previous studies and our own data, we discussed that the
sociocultural differences such as the degree of medicalisation of the
population and awareness of CFS among the population and the medical
professionals might have contributed to the current findings.[1-3]
We have not specifically addressed alternative local formulations for the
problems resembling CFS in Brazil. However, our case vignette study using a
typical history of CFS according to the CDC definition revealed that the
most common diagnoses given by Brazilian doctors were psyhcological
disorders,[3] hence providing some information regarding the question raised
by Paralikar et al. In order to address this and other important questions,
we have collected qualitative data through in-depth interviews of
chronically fatigued individuals in Brazil and these data are currently
being analysed.
We agree with Dr Paralikar and colleagues that the pattern of recognition
and labelling observed in Brazil is not a failing since this pattern is
probably due to the sociocultural context rather than due to the medical
incompetence. Indeed, we never suggested it was a failure.
Finally, the study by de Fatima de Marinho de Souza et al[4] has actually
used the same questionnaire as the current study: the Chalder Fatigue
Questionnaire. A more inclusive concept of chronic fatigue, as
operationalised by this questionnaire, was also used in the current study,
namely unexplained chronic fatigue as we additionally performed the
screening for medical causes. The prevalence of unexplained chronic fatigue
was also similar in the two settings.
1. Cho HJ, Menezes PR, Hotopf M, Bhugra D, Wessely S. Comparative
epidemiology of chronic fatigue syndrome in Brazilian and British primary
care: prevalence and recognition. Br J Psychiatry 2009;194:117-122.
2. Cho HJ, Bhugra D, Wessely S. 'Physical or psychological?' - A comparative
study of causal attribution for chronic fatigue in Brazilian and British
primary care patients. Acta Psychiatr Scand 2008; 118: 34-41.
3. Cho HJ, Menezes PR, Bhugra D, Wessely S. The awareness of chronic fatigue
syndrome: A comparative study in Brazil and the United Kingdom. J Psychosom
Res 2008; 64: 351-355.
4. de Fatima Marinho de Souza M, Messing K, Menezes PR, Cho HJ. Chronic
fatigue among bank workers in Brazil. Occup Med (Lond) 2002;52:187 -194.
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