Chronic fatigue syndrome: is the biopsychosocial model responsible for patient dissatisfaction and harm?

Keith J Geraghty; Aneez Esmail

doi:10.3399/bjgp16X686473

Published eLetters

eLetter submission guidelines

Submit a Response to This Article

Compose eLetter

Title *

Author Information

Contributors

First Name and Middle Initial *

First or given name, e.g. 'Peter'.

Last Name *

Your last, or family, name, e.g. 'MacMoody'.

Email Address *

Your email address, e.g. higgs-boson@gmail.com. PLEASE NOTE: your email address will be published.

Occupation *

Your role and/or occupation, e.g. 'Orthopedic Surgeon'.

Affiliation *

Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.

Statement of Competing Interests

Competing interests? *

Yes

Please describe the competing interests

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

Jump to comment:

Chronic fatigue syndrome: is the biopsychosocial model responsible for patient dissatisfaction and harm?
Nasim Marie Jafry

Published on: 23 August 2016
Chronic fatigue syndrome: is the biopsychosocial model responsible for patient dissatisfaction and harm?
Angela Patricia Kennedy

Published on: 04 August 2016
Chronic fatigue syndrome: is the biopsychosocial model responsible for patient dissatisfaction and harm?
John Peters

Published on: 31 July 2016
Chronic fatigue syndrome:is the biopsychosocial model responsible for patient dissatisfaction and harm?
Peter D. Campion

Published on: 30 July 2016

Published on: (23 August 2016)
Page navigation anchor for Chronic fatigue syndrome: is the biopsychosocial model responsible for patient dissatisfaction and harm?
Chronic fatigue syndrome: is the biopsychosocial model responsible for patient dissatisfaction and harm?
Nasim Marie Jafry, ME sufferer
I was pleased to see this article highlight the potential harms of GET and CBT for patients with ME. I myself was diagnosed with ME as a 20 year old student in early 1984 by a consultant neurologist in Glasgow - my illness was triggered by Coxsackie B4 virus - there was an outbreak of Coxsackie in the West of Scotland at this time. Since my own diagnosis with this poorly understood illness, I have been baffled - and shocked - to see the criteria of ME diluted in the early 1990s and the consequent conflation with unexplained 'chronic fatigue'. Moreover, the adoption of the biopsychosocial model of 'ME/CFS' has certainly not been beneficial to my own experience of illness. I am hopeful that with the dedicated international biomedical researchers we now have, there will be effective therapies in my lifetime. There are many, many people who truly suffer with this dreadful illness.

Competing Interests: None declared.
Published on: (4 August 2016)
Page navigation anchor for Chronic fatigue syndrome: is the biopsychosocial model responsible for patient dissatisfaction and harm?
Chronic fatigue syndrome: is the biopsychosocial model responsible for patient dissatisfaction and harm?
Angela Patricia Kennedy, Sociologist, Carer, Disabled person, Independent
Geragthy and Esmail may be interested to learn there have been various previous critiques of the 'biopsychosocial model'. My own academic critique (also referencing others) made in 2012^1-2demonstrated Engel's fallacies of reasoning as he advanced psychogenic explanations of physical impairments. He also ignored the impact of physical impairment on people's lives, a problem also seen, for example, in a 'CFS/ME' department response to the NICE Guidelines,³ where they objected to providing blue badges and wheelchairs to patients or managing the adverse impact of the disease on their patients' lives. Considering the research indicating chronicity and poor prognosis; the WHO ICD-10 classification as a neurological disease; and higher level of physical impairment and 'disability' in ME/CFS than multiple sclerosis, end-stage renal disease and heart disease, this response was astounding.

As Mary Horton-Solway⁴ comments:

"The use of bio-psycho-social reasoning appears somewhat different from the theoretical vision of a holistic disease-process model…"

Patients facing a 'biopsychosocial approach' find an over-emphasis on the 'psycho' (and only then with regard to alleged causation, rather than impact), at the expense of 'bio' and 'social' aspects of their impairments, leading to psychogenic dismissal and malign constructions o...
Show More

Geragthy and Esmail may be interested to learn there have been various previous critiques of the 'biopsychosocial model'. My own academic critique (also referencing others) made in 2012^1-2demonstrated Engel's fallacies of reasoning as he advanced psychogenic explanations of physical impairments. He also ignored the impact of physical impairment on people's lives, a problem also seen, for example, in a 'CFS/ME' department response to the NICE Guidelines,³ where they objected to providing blue badges and wheelchairs to patients or managing the adverse impact of the disease on their patients' lives. Considering the research indicating chronicity and poor prognosis; the WHO ICD-10 classification as a neurological disease; and higher level of physical impairment and 'disability' in ME/CFS than multiple sclerosis, end-stage renal disease and heart disease, this response was astounding.

As Mary Horton-Solway⁴ comments:

"The use of bio-psycho-social reasoning appears somewhat different from the theoretical vision of a holistic disease-process model…"

Patients facing a 'biopsychosocial approach' find an over-emphasis on the 'psycho' (and only then with regard to alleged causation, rather than impact), at the expense of 'bio' and 'social' aspects of their impairments, leading to psychogenic dismissal and malign constructions of their characters (as hypochondriacs, malingerers, wimps). Whatever the ostensible holistic "treating the patient as a whole person" philosophy claimed by proponents of 'biopsychosocial' approaches, they are used most often to assume that physical illness is caused by psychopathology and deviance, and to advocate management based on this belief. When considered under a social model of disability,⁵ they can be drivers of 'disability'. Health professionals need to consider and resolve this problem: otherwise they may well be contributing to dangerous, ableist treatment of disabled people.

References

1. Kennedy, A. Authors of our own Misfortune? The Problems with Psychogenic Explanations for Physical Illnesses. 2012, Village Digital Press, Market Rasen
2. Black Triangle Campaign. Academic Angela Kennedy Responds to Professor Sir Mansel Aylward’s Statements to Black Triangle and DPAC. http://blacktrianglecampaign.org/2012/09/19/academic-angela-kennedy-responds-to-professor-sir-mansel-aylwards-statements-to-black-triangle-and-dpac/ {accessed 8 Aug 2016}.
3. ME Agenda. A Selection of points the Barts CF Service made during the NICE Guidelines for CFS / ME: Tom Kindlon. https://meagenda.wordpress.com/2007/09/06/a-selection-of-points-the-barts-cf-service-made-during-the-nice-guidelines-for-cfs-me-tom-kindlon/ {accessed 8 Aug 2016}
4. Horton-Solway, M. Bio-Psycho-Social Reasoning in GP’s Case Narratives: The Discursive Construction of ME Patients’ Identities. Health 2002; 6: 401-421.
5. Oliver, M. The Social Model of Disability: Thirty Years on. Disability and Society 2013; 28:7,1024-1026.

Show Less

Competing Interests: I have undertaken key academic work (critiques) on the 'biopsychosocial' approach and other issues related to psychogenic explanations of physical impairment. I am currently researching psychogenic explanations informing disability denial, as ideology and practice, in health care, 'welfare' and political contexts. I am disabled in my own right, and a full-time carer to another disabled person.
Published on: (31 July 2016)
Page navigation anchor for Chronic fatigue syndrome: is the biopsychosocial model responsible for patient dissatisfaction and harm?
Chronic fatigue syndrome: is the biopsychosocial model responsible for patient dissatisfaction and harm?
John Peters, patient
Geraghty & Esmail are right to draw attention to the harm done to the doctor-patient relationship by the biopsychosocial model of ME. The doctor considers the patient an unreliable witness to their own illness and so does not trust the patient; the patient knows the doctor does not trust them and so does not trust the doctor.

There are many other harms:
1.   Patients are pained simply from being seen as an unreliable witness to their own body and illness. Enduring devastating symptoms, mourning the loss of their life, patients are distressed to be told that the illness is a function of their belief; that the knowledge they are ill is a false belief; and, implicitly, that the power to recover lies simply within themselves.
2.   Patients are disempowered. Not only does 'doctor know best', but anyone who feels the urge to express an opinion: family, friends, acquaintances, strangers, online commentators. Since the patient can not be considered reliable then everyone knows better.
3.   Patients are harmed by the popular perception of the illness which follows from the biopsychosocial designation. While many who work in the field would never use the term, the illness is understood as 'all in the mind'.
4.   Patients' relationships to the wider society are harmed. Governments are encouraged to question the payment of benefits to avoid encouraging patients...
Show More

Geraghty & Esmail are right to draw attention to the harm done to the doctor-patient relationship by the biopsychosocial model of ME. The doctor considers the patient an unreliable witness to their own illness and so does not trust the patient; the patient knows the doctor does not trust them and so does not trust the doctor.

There are many other harms:
1.   Patients are pained simply from being seen as an unreliable witness to their own body and illness. Enduring devastating symptoms, mourning the loss of their life, patients are distressed to be told that the illness is a function of their belief; that the knowledge they are ill is a false belief; and, implicitly, that the power to recover lies simply within themselves.
2.   Patients are disempowered. Not only does 'doctor know best', but anyone who feels the urge to express an opinion: family, friends, acquaintances, strangers, online commentators. Since the patient can not be considered reliable then everyone knows better.
3.   Patients are harmed by the popular perception of the illness which follows from the biopsychosocial designation. While many who work in the field would never use the term, the illness is understood as 'all in the mind'.
4.   Patients' relationships to the wider society are harmed. Governments are encouraged to question the payment of benefits to avoid encouraging patients in their illness beliefs.
5.   The patient-family relationship is damaged: families are told to challenge the patient's false beliefs. They look differently at their family member when told the patient has the power to recover within them. Families are not receiving the information, help and support they need.
6.   Since patients do not respond to therapy, therapists are harmed. Therapists become frustrated with the patient or with themselves for this failure.
7.   Other patients, with illnesses which may respond to therapy, are unable to get the help they need because therapists are wasted on ME patients.
8.   Research priorities are distorted.
9.   Persisting with a diagnosis with no scientific basis is harmful in itself: damaging to science and public confidence.

It is time the UK followed the USA and dumped the failed, unevidenced, harmful biopsychosocial model.

Show Less

Competing Interests: None declared.
Published on: (30 July 2016)
Page navigation anchor for Chronic fatigue syndrome:is the biopsychosocial model responsible for patient dissatisfaction and harm?
Chronic fatigue syndrome:is the biopsychosocial model responsible for patient dissatisfaction and harm?
Peter D. Campion, Retired academic GP,, University of Hull
Geraghty and Esmail have done well to draw attention to the substantial biomedical literature now extant around chronic fatigue syndrome (CFS). They are right to point out that the dominant model has been a biopsychosocial (BPS) one, and that this has led to persistent disagreement between doctors and patients. What is particularly salutary is the absence of any advance in therapy, so that they recommend for example cognitive behaviour therapy, but with the caveat that it might not be helpful in individual cases. CFS continues to challenge GPs by its resilience to treatment, but colleagues will be well advised to take on board the changing evidence for pathophysiology set out in this article. Many of the cited papers are accessible and worth reading, such as the authors' reference 8¹, and in that paper, reference 38.²

The bottom line for me is respect for the patient, and humility in the face of lack of knowledge about the precise causes of CFS, which is clearly anyway a heterogenous group of conditions.

References

1. Twisk NM, Geraghty KG. Deviant Cellular and Physiological Responses to Exercise in Myalgic Encephalomyelitis and Chronic Fatigue Syndrome. J J Physiology 2015, 1(2): 007.

2. Meeus M, Roussel, N A, Truijen, S, Nijs, J. Reduced pressure pain thresholds in response to ex...
Show More

Geraghty and Esmail have done well to draw attention to the substantial biomedical literature now extant around chronic fatigue syndrome (CFS). They are right to point out that the dominant model has been a biopsychosocial (BPS) one, and that this has led to persistent disagreement between doctors and patients. What is particularly salutary is the absence of any advance in therapy, so that they recommend for example cognitive behaviour therapy, but with the caveat that it might not be helpful in individual cases. CFS continues to challenge GPs by its resilience to treatment, but colleagues will be well advised to take on board the changing evidence for pathophysiology set out in this article. Many of the cited papers are accessible and worth reading, such as the authors' reference 8¹, and in that paper, reference 38.²

The bottom line for me is respect for the patient, and humility in the face of lack of knowledge about the precise causes of CFS, which is clearly anyway a heterogenous group of conditions.

References

1. Twisk NM, Geraghty KG. Deviant Cellular and Physiological Responses to Exercise in Myalgic Encephalomyelitis and Chronic Fatigue Syndrome. J J Physiology 2015, 1(2): 007.

2. Meeus M, Roussel, N A, Truijen, S, Nijs, J. Reduced pressure pain thresholds in response to exercise in chronic fatigue syndrome but not in chronic low back pain: an experimental study. J Rehabil Med 2010; 42: 884–890

Show Less

Competing Interests: None declared.