Given that friends in England are under attack by the Wessely school,
the British media, etc., I think it is time for some logic once again.
Therefore, I am re-posting this review.
Pardon moi if the article is somewhat outdated from a research standpoint=
,
and in light of the new case definition for M.E. There has been
considerable research done since this was written. Due to illness,
aging parents & other responsibilities, my website has not been updated i=
n
two years.
The term "CFS" used in this article is outdated, at best. There has been =
a
new case definition for M.E that I've not been well enough to put on the =
site
to update it, as of yet. The outdated term "CFS" is used throughout th=
is
article. However, this review still stands as a logical refutation of the
Wessely school's position. I regret to say that at the time I did not sp=
end
enough words discussing the financial conflicts of interest of the Wessel=
y
school. Once again, new-age science/pseudoscience from the Wessely scho=
ol:
New Age "Science" or Pseudoscience: A Review of Mark Demitrack's and Susa=
n
Abbey's _Chronic Fatigue Syndrome: An Integrative Approach to Evaluation
and Treatment_
by Maryann Spurgin, Ph.D.
The basic thesis of Demitrack's and Abbey's book, Chronic Fatigue Syndrom=
e:
An Integrative Approach to Evaluation and Treatment, is that the conditio=
n
is a post-infectious, but culture-specific, behavioral and interpretive
disorder, or at least, it is a condition caused and perpetuated by behavi=
or
and interpretation. It occurs in patients who refuse to exercise because
they misinterpret their symptoms as severe and as representative of damag=
e
to the body. The patients' belief system is responsible for their failure
to recover, since it leads to deconditioning, the real source of the
patients' debilitation.
According to this thesis, some 2 million people across the country, peopl=
e
whom the book theorizes were often of above-average intelligence before
they got sick, developed a viral infection or some other bodily stressor
and then, suddenly, their interpretation became skewed. Suddenly they beg=
an
imagining that their symptoms continued beyond the acute, infectious stag=
e
and that those symptoms were severe. Such "attributions" and "cognitions"
perpetuate the illness, as does the "attributional bias" of the physician=
s
who take them seriously. The cure, according to the book, is Cognitive
Behavioral Therapy, which alters the faulty cognitions and leads to new
behaviors such as exercise. Exercise, according to the book, restores the
patient to normal.
Elegant prose and cool, clinical language provide the book with an aura o=
f
scientific objectivity. Careful examination, however, reveals the book to
contain more value-laden rhetoric than logic, more religion than science.
Let's examine its authors' cognitions and attributions.
LOGICAL FALLACIES
The book's principle logical errors are (1) fallacy of Undistributed
Middle, (2) self-contradictory statements, (3) circular reasoning, and (4=
)
fallacies of division and composition. Let's examine the book's fallaciou=
s
reasoning by Undistributed Middle. Suppose I made the following argument:
All cats have hair.
All dogs have hair.
Therefore, all cats are dogs. The absurdity of the argument is obvious,
since cats are not dogs. It is fallacious to conclude that because two
entities share some characteristics, they are the same entity and should =
be
treated the same way. Demitrack employs this fallacious reasoning in his
first full chapter, Chapter 4, where he discusses endocrinology and
immunology. After an extensive discussion of immunological deficits in CF=
S,
including reductions in Natural Killer (NK) cell function and number,
evidence of T-cell activation, impaired cell-mediated immunity, reduced
lymphocyte proliferative responses to in vitro mitogen stimulation, and
more, Demitrack immediately informs the reader that some of the same immu=
ne
aberrations appear in major depression, anorexia nervosa, bereavement, an=
d
psychological stress. The implied conclusion, of course, and the one the
unsophisticated reader walks away with, is that CFS, too, is one of these
latter states or something similar to one of these states. As an analogy,
on Demitrack's reasoning, one might also conclude that AIDS, too, is not =
a
viral infection or a primary immunological disease, but rather a mood
state, since lowered NK cell function is seen in that disease as well. On=
e
might, following Demitrack's reasoning, proceed to treat AIDS with
psychotropics rather than anti-virals. (The absurdity of doing so is
obvious only because we now know it to be both viral and fatal, but prior
to knowing this the absurdity is not so obvious.) It is likewise fallacio=
us
to conclude that because impaired immunity is a finding in both CFS and
some psychiatric disorders, CFS is a psychiatric disorder.
The book artfully interprets the data with regard to endocrinology as wel=
l
as immunology. Mark Demitrack is known for having compared cortisol level=
s
in CFS patients with those of the melancholically depressed. While raised
cortisol levels are a finding in depression, Demitrack discovered that CF=
S
patients express lowered cortisol. Instead of interpreting this finding t=
o
mean that CFS patients were unlike depressed patients, Demitrack labors t=
o
find an interpretation that would again link CFS to depression: he propos=
es
that there are other depressive states in which lowered cortisol is expre=
ssed.
At the same time, the book claims that depression is present in CFS, and
that the therapist should assume it, even when the patient denies it and
his or her actions do not support it. Indeed, the book goes so far as to
say that if the therapist becomes depressed in talking to the patient, th=
e
patient is likely depressed. This is a highly subjective way of doing
"science" and medicine. It raises this general question: just how vague c=
an
a science become without compromising its claim to being science at all?
Psychological assessments are often ones that are based on the subjective
opinions of the therapist ("I don't like you, therefore you're mental")
often with no objective data. In this case, the data show the opposite of
what Demitrack and Abbey were looking for, yet get reinterpreted into the
old scheme. Where federal funding is concerned, it would appear that no
amount of objective data that surfaces showing CFS to be distinct from
depression and possibly indicative of viral chronicity and/or infectious =
or
post-infectious neurodegeneration is sufficient to tear down long held
subjective beliefs, cognitions, and attributions by federally associated
researchers. Indeed, some beliefs just run too deep for reason.
Demitrack's treatise also falls prey to circular reasoning. On page 21, h=
e
states that "persistent Epstein Barr virus infection is almost certainly
not tenable for most cases of the syndrome." This may be a true statement.
But what about some of the cases? Earlier, he admitted that Epstein Barr
virus can be a chronic infection and that there are documented cases of
chronic Epstein Barr virus infection. Further, those cases meet the CDC
case definition for CFS. Elsewhere in the book, Komaroff states that many
of the viruses found and implicated in CFS (HHV-6, etc.) can also be
chronic. Some of these are known to be serious infections. Yet despite
Komaroff's focus on viral chronicity, Demitrack decides to exclude the
chronically infected, whom he admits exist, from the CFS picture. He then
goes on to exclude patients with any other objective signs of disease. On
page 95, for example, he selects out of the definition of CFS those with
neurological symptoms and signs. In discussing brain lesions detected by
MRI, he urges us to adopt an alternative "interpretation" of this finding=
:
". . . Although most of the patients [showing MRI abnormalities] appeared
to meet the subsequently published clinical criteria for chronic fatigue
syndrome, the possibility that an alternative neurodegenerative disease w=
as
present in a subset of the group could not be excluded. Indeed, symptoms
[were] not typical of most individuals with chronic fatigue syndrome . . .
seizures, ataxia, paresis, . . ."
What might these "alternative neurodegenerative diseases" be? Demitrack
doesn't say, nor does he tell the reader why he has decided not to focus =
on
them. In short, Demitrack selects out of the definition of CFS anyone wit=
h
chronic infection, neurological problems, and other objective signs of
disease, only to draw the circular conclusion that CFS is neither a chron=
ic
infection nor a neurodegenerative disease (but instead a subjective belie=
f
system leading to faulty behavior). It is odd that the book accuses
patients and their doctors of faulty cognitions when it would seem that,
like Straus, Demitrack has failed to master the simple rules of elementar=
y
logic, and begs the question to "prove" his conclusions.
It is false that seizures, ataxia, and paresis are uncommon in CFS. They
are only uncommon if one defines them as not being part of the CFS
pathology. Why in Demitrack's treatise do the more seriously ill drop out
of the discussion? Why would he want to exclude the more serious cases fr=
om
study? Couldn't more be learned from them? The only plausible answer is
that learning is simply not a goal here. The seriously ill are excluded
from study because they testify against the behavioral hypothesis.
The authors of the book also take to contradicting themselves. For exampl=
e,
the book states that persons with preexisting psychiatric conditions
undergo prolonged recovery or fail to recover from viral infections more
frequently than persons without such conditions. Empirical studies in
psychology have indeed shown that persons with, say, depression, or even
persons whose mother died in their childhood and hence are predisposed to
pessimism, do develop all forms of illness (cancer, infections, etc.) mor=
e
frequently than persons without a pessimistic outlook. Yet it is one thin=
g
to say that some psychiatric states contribute to prolonged recovery or
failed recovery from viral infections or render individuals more
susceptible to infections. It is quite another to say -- contradicting
oneself -- that having failed to recover from a viral infection they do n=
ot
have a viral infection. This contradiction occurs repeatedly throughout t=
he
book.
Of course, given that the DSM-IV tends to pathologize and clinicize the
entire range of human behavior and experience -- everything from clumsine=
ss
(315.4) and snobbery (301.7) to snoring (780.59) and coffee drinking
(305.90) are mental disorders according to the DSM-IV -- one can easily u=
se
the manual to justify a claim that any group had preexisting psychiatric
disease. Thus, the view that "most" CFS patients had preexisting
psychiatric disorder is highly subjective.
The two chapters in the book on CBT -- one by Simon Wessely and one by
Michael Sharpe -- offer a discussion of patients in a tone of profound
hostility, misogyny, and disrespect. Patients don't relapse with exertion=
,
Sharpe states, nor does their condition deteriorate following exertion --
that's only an "interpretation." He suggests that the therapist review wi=
th
the patient the "evidence" for the belief that post-exertional symptoms
signify disease progression. The patient should "generate more benign
explanations of [symptom] exacerbation," he says, and "regard the symptom=
s
as positive evidence of an effective challenge to the pathophysiology of
the illness" (p. 254).
Like Demitrack, Sharpe seems to hold that personal psychology determines
reality. If I think I'm well, I am. A benign explanation of the symptoms,
simply, makes them benign. Perhaps Sharpe could cure all diseases by
applying this simple reasoning: cancer is only cancer if you think it is,
likewise with AIDS, and so on. Indeed, perhaps if Sharpe thinks he can fl=
y
he won't be squashed when leaping from tall buildings. At the same time,
Sharpe seems to hold that symptom exacerbation -- e.g., increased pain,
weakness, flu symptoms, blurred vision, hot/cold chills, shaking chills,
fainting, vertigo, parasthesias, night sweats, neuropathies, numbness,
paralysis, tachycardias, cardiac arrhythmias, and dementia -- are a
positive sign, something the editors and contributors of the book also
hold. Again, perhaps they could expand their thesis for other diseases:
positive signs are what increase arthritis symptoms, increase an AIDS
patient's viral load, exacerbate the symptoms of lupus, and so forth. If
one follows the reasoning of the book to its logical conclusions, one mig=
ht
seriously begin to question not only the cognitions of its authors but
perhaps even their sanity.
Despite his suggestion of reviewing the "evidence" for the belief that
symptoms are severe and represent disease progression, Sharpe himself (an=
d
the book in general) selectively ignores well-published data showing that
exertion is harmful in CFS, data showing exercise-induced neuroendocrine
deficits, oxygen deficits, cardiac ischemia and other cardiac involvement=
,
worsened SPECT, IQ drops, etc. (by Cheney, Natelson, Simpson, Lerner, and
others). Nor does Sharpe offer studies that confirm his cognition that th=
e
patient is misinterpreting his or her symptoms as more severe than they a=
re.
Finally, it is difficult to overlook the striking similarity of Straus's
and Demitrack's thesis to the simplistic New Age models of disease that
currently saturate the popular media. Demitrack dresses the model in
sophisticated prose and seemingly scientific language, but the core thesi=
s
is the same: believe yourself well, and you will be. Or, as Demitrack put=
s
it, "the formulation of alternate [i.e., non-infectious] models of diseas=
e
. . . is imperative to favorable outcome." He suggests that "observer bia=
s"
was responsible for the infectious model of the disease in past epidemics=
,
and sees himself as quite unbiased in the view that it's all a matter of
how you think -- personal beliefs determine reality: "Greater functional
impairment was associated with factors such as the patient's belief in a
viral cause [and] ... the limiting of exercise." It never occurs to the
authors that those who think they have a viral infection may actually hav=
e
one, or that the functional impairment and exercise limitations may be a
result of (not a cause of) severe, systemic disease. For them, it is the
belief in viral causality that impairs recovery: ". . . the profound
disability of CFS may lie in the cognitions of those afflicted" (p. 227).
In fact, the book seems to suffer from a philosophical confusion of fact
and concept: "Chronic fatigue syndrome is an illness that is formed . . .
by the complex context in which it is diagnosed . . ." Demitrack states, =
in
one of his many moments of a dishonest and underhanded version of
philosophical idealism. While it may be true that the concept of CFS is
formed by diagnostic contexts -- diseases themselves are entities that
occur quite independently of conceptual contexts, however close or far aw=
ay
we are from a conceptual grasp of those diseases. This is a point that is
lost on -- or perhaps deliberately obscured by -- Demitrack and his
contributors. This conceptual confusion also occurs repeatedly in Straus'=
s
work (who once stated that the wave of chronic mononucleosis that swept
across the U.S. in the 1980's resulted from physicians' misinterpretation
of laboratory tests).
The book discourages the search for causes as "futile." It ignores or
dismisses all serious attempts to understand the syndrome and offers fals=
e
information to physicians, dismissing all data that disconfirm its
behavioral thesis. Physicians who believe their patients are portrayed as
enablers who perpetuate the disease and who themselves have "attributiona=
l
bias" (the authors are, of course, bias free, as is anyone who adopts the
behavioral thesis).
Demitrack, Straus, Abbey, Wessely, and Sharpe are surely and most certain=
ly
right that there are behaviors that perpetuate CFS. Unfortunately, they a=
re
the very behaviors that these authors recommend. This is a dangerous book
that will perpetuate misconceptions at best and, at worst, cause harm. My
concern is for children who will suffer abuse at the hands of physicians =
as
a result of this book. Chronic Fatigue Syndrome: An Integrative Approach =
to
Evaluation and Treatment is not a serious, scientific attempt to understa=
nd
a disease that has crippled adults and children across the country.
Instead, it is a poorly reasoned, conceptually confused, biased piece of
rhetoric and trendy New Age religion. The authors state that the patients=
'
belief that their disease is a catastrophe is a "mind trap" and a
"cognitive error." Perhaps if Demitrack and Abbey had mastered a few
elementary rules of logic, they would have fallen into fewer mind traps a=
nd
cognitive errors of their own.
=A9 Copyright 1997 Medical Professionals With CFIDS
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