AHMF: Guidelines response Phillips

Dr Nicole Phillips

I am a psychiatrist, medical educator, writer and medical editor and advisor to the ME/CFS Association of Victoria as well as an ex-sufferer of CFS.

I would like to congratulate the working party on the effort gone into the new draft.

I would like to make the following suggestions:

(1) p. 18 Para 2

The term neurasthenia is an outdated English psychiatric term which some CFS researchers are trying to revive. The DSM psychiatric classification system used in America and Australia has not used this term for many years, on the basis of its lack of validity. It has no place in a section on "other terms for CFS" other than to be mentioned and dismissed.

(2) p. 21 Para 2

The first statement is totally erroneous, "the most difficult diagnostic uncertainty between CFS and psychological illness" is not in relation to somatoform disorder but depression. The somatoform disorders are subdivided into the following:

Somatisation Disorder
Undifferentiated Somatoform Disorder
Conversion Disorder (used to be hysteria)
Pain disorder
Hyochrondriasis
Body Dysmorphic Disorder
Somatoform Disorder not otherwise specified.

If a sound psychiatric and physical history is taken, these disorders can, in most cases, be clearly differentiated from CFS. In Somatoform Disorder there is usually significant personality dysfunction with a disturbed childhood, alexithymia (difficulty putting words to feelings) and secondary gain from being ill. In CFS, there are clearly defined physical symptoms as defined by the Fukuda criteria and lack of the psychodynamics seen in the former.

(3) p. 22 Para 1

The study by Wilson, in which 19% of patients followed up developed "other psychological disorders" firstly implies that their original fatigue condition was "psychological", and also does not state the important point that in any chronic illness, coexistent depression is common—in fact, most studies provide figures in other medical illnesses of greater than 19%.

(4) p. 23

Re "leading hypotheses". The first 3 are certainly leading. The last 2 points are hypotheses but are not "leading". There has been more than enough evidence, including HPA axis work, to dispel Wessley's "depression hypothesis" as invalid. The references to the last point about it being a "psychological" response in "vulnerable individuals" are outdated (1961 and 1993)—the purely psychological hypothesis has no validity in 2001.

(5) p. 27 Para 2

"Other commonly detected disorders", when assessing fatigue states—everything is fine until "panic disorder, generalised anxiety and somatoform disorders".

In panic disorder and generalised anxiety, fatigue is not a core feature. In DSM IV, fatigue is not even mentioned in the diagnosis of panic disorder. In Generalised Anxiety Disorder (GAD) "being easily fatigued" is only one of many possible symptoms and does not have the same quality as the chronic relentless nature of the fatigue in CFS. The issue of somatoform illness has been discussed earlier.

(6) p. 28

Last para "Most people with depressive disorders ...". In reality, people with depression can present in many ways. Fatigue and/or pain is not the most likely presentation at all. In summary, the document shows bias from certain psychiatric researchers in the area. The committee needs to address this without detracting from the holistic approach to the illness. In particular, terms like "neurasthenia" have no validity in the current CFS debate.

Yours sincerely

Dr Nicole Phillips
Medical Editor, Emerge, ME/CFS Association of Victoria