EBV-requisitioning physicians’ guess on fatigue state 6 months after acute EBV infection

Abstract:

We assessed referring medical practitioner’s ability to predict chronic fatigue development in adolescents presenting with acute infectious mononucleosis. Compared with ‘not fatigued’ being predicted as ‘unsurely fatigued’ and ‘likely fatigued’ were both strongly associated with developing fatigue 6 months later (OR 2.5, 95% CI 1.16% to 5.47% and 3.2, 95% CI 1.19% to 8.61%, respectively, P=0.012). The positive and negative predictive values were 66% and 62%, respectively. Disentangling the physician’s intuition may be of interest in further investigations of risk factors and prophylactic factors for fatigue development.

Source: Asprusten TT, Pedersen M, Skovlund E, Wyller VB. EBV-requisitioning physicians’ guess on fatigue state 6 months after acute EBV infection. BMJ Paediatr Open. 2019 Mar 1;3(1):e000390. doi: 10.1136/bmjpo-2018-000390. eCollection 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6422241/ (Full article)

Dismissing chronic illness: A qualitative analysis of negative health care experiences

Abstract:

In the US, medical training is inadequate regarding the symptomatology, prognosis, and treatment for myalgic encephalomyelitis (ME) and chronic fatigue syndrome (CFS). As a result, many physicians lack the appropriate level of knowledge about effective methods for ME and CFS symptom reduction and often suggest inappropriate treatments, such as increased exercise or psychiatric services. The authors’ purpose in this study was to analyze negative patient experiences with health care professionals.

Patients with ME and CFS who reported experiencing a dismissive physician attitude were asked to detail the encounter via open-ended response on an international, online survey. Participant responses were thematically coded and analyzed using processes outlined by Patton. Emergent themes related to perceived physician attitudes and how they impact patient wellbeing are described and their implications discussed. Additionally, we highlight suggestions for how the health care system can effectively approach this often marginalized patient group.

Source: McManimen S, McClellan D, Stoothoff J, Gleason K, Jason LA. Dismissing chronic illness: A qualitative analysis of negative health care experiences. Health Care Women Int. 2019 Mar 4:1-18. doi: 10.1080/07399332.2018.1521811. [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/30829147

Parliamentary Debate: Kids being taken into care by medics who refuse to believe ME is real

Press Release: January 25, 2019, John Siddle, ME Association (UK).

Children with the devastating illness ME face the threat of being taken into care because medics refuse to accept their disease is real, parliament was today told.

ME – myalgic encephalomyelitis – is a cruel disease affecting a quarter of a million people in the UK who are being “failed” in a “national disgrace”.

While classed as a neurological disease, the stigmatised condition is still considered wrongly by some health professionals to be psychological. It means that often patients struggle to get the support they so desperately need.

ME manifests as activity-induced muscle fatigue, post-exertional malaise, problems with cognitive function, widespread muscle pain, unrefreshing sleep and ongoing flu-like symptoms.

In the debate today – the first in 20 years on ME – the House of Commons was told how one in five children with the disease are being threatened with the prospect of being forced into care.

MP Carol Monaghan, who brought today’s motion, led calls for more funding for research and better medical training to help support patients.

She said: “There is currently no cure for ME and many with the condition experience inadequate care and support.

“But there are an estimated quarter of a million people in the UK suffering from ME, and currently we are letting these people down.

“The cause of the disease is unknown, but many patients report that it developed after a viral infection such as flu or glandular fever.

“Many adults cannot maintain employment or relationships with family and friends, while children frequently fall behind in school. The ignorance surrounding the condition makes it harder to access benefits with DWP assessors often deciding the sufferer is fit for work.”

Several quality of life research studies have shown that the level of disability in ME can be just as great than many other serious medical conditions, including cancer and multiple sclerosis.

While some people with ME do improve over the course of time, it is only a small minority that return to full normal health. And the disease is indiscriminate, affecting both sexes, all ages and all races.

Mrs Monaghan, (SNP, Glasgow North West) added:

“Some with severe ME spend their days in darkened rooms, unable even to watch TV or listen to music.  Even touch is intolerable. Many are tube fed. For these individuals, ME is a life sentence, but a life spent existing, not living.

“This condition is largely unknown because those affected are often hidden away. I commend the ME community for lobbying so successfully to ensure so many members are here today.

“Leading up to this debate, I have been asked repeatedly what I hope to achieve. Ultimately what I want, and what the ME community wants, is better treatment and care for those with ME.”

Child protection proceedings

The debate was told how one in five families caring for a child with the devastating disease ME have been referred for child protection proceedings.

The Commons told how an eight-year-old – Girl B – was almost taken from her family by social services after medics said her condition was psychological.

Mrs Monaghan continued: “B’s parents were warned that if they did not fully comply, child protection proceeding would be initiated. Social services specified graded exercise, despite being warned of the dangers. As a result, B deteriorated rapidly until she became wheelchair bound. “

Under threat of court action, the girl’s parents were then forced to take her to a children’s hospital and threatened with the prospect of their daughter being taken into foster care.

Mrs Monaghan continued: “B was in constant pain, unable to sit upright, with her head hanging down the side, crying in distress.

“This continued for five months and her parents were threatened that if B didn’t progress, she’d be transferred to a psychiatric unit or placed in foster care.”

It was only when the girl’s parents sought the intervention of the secretary of state, that the girl was allowed home and removed from the ‘at risk’ register.

Suspension of controversial therapies

Ms Monaghan, who also called for the suspension of controversial Graded Exercise Therapy and Cognitive Behaviour Therapy as recommended treatment programmes, added: “A firm diagnosis of ME protects the child from these proceedings but unfortunately paediatricians are often reluctant to give this – simply because they do not understand the condition – which leaves the child open to social service intervention.

“This is a national disgrace and needs urgent action. Children who are already blighted by ME must not be subjected to this trauma.”

Improving medical education

Steve Brine, parliamentary under-secretary for health, responded to the debate, saying that, “The Government do not for one-minute underestimate ME.”

“We know that the condition has a devastating impact,” adding, “we cannot for one minute begin to understand what it must be like to suffer from this condition.”

Mr Brine said nobody with ME should ever “be fobbed off by the medical profession.” He said that before the debate he had spoken with the chair of the Royal College of GPs – Prof. Helen Stokes-Lampard – and will organise a future discussion on improving medical education and awareness.

“The NICE guidance is clear on a number of important points. There is no one form of treatment to suit every patient; that is self-evident. The needs and preferences of patients should absolutely be taken into account. Doctors should explain that no single strategy will be successful for all patients, which is a hallmark of this condition.

“In common with people receiving any NHS care, ME patients have the absolute right to refuse or withdraw from any part of their treatment; nobody is making this happen. Those with severe symptoms may require access to a wider range of support, managed by a specialist.”

Research funding

On the subject of research funding for ME, Mr Brine said that it wasn’t the Governments responsibility to allocate specific funding, and that the problem lay with the quality of research applications.

He said, “The truth is – sometimes it is a hard and inconvenient truth to hear—there have not been good enough research proposals in the ME space, partly because of the stigma and partly because of the division in the medical community. We need people to come forward with good research proposals in this space; that can only be advantageous.”

In closing, Mrs Monaghan replied that, “On the question of medical research, I am sure that many researchers will have heard what he said. However, it is notable that although there is some excellent biomedical research going on just now, it is being funded by charities, and not by the Government. The Government need to take this seriously.”

The ME Association

The ME Association is at the forefront of improving access to care, treatment and research and removing the disease’s stigma.

Despite being recognised by the World Health Organisation as a neurological disease, and a report from the Chief Medical Officer of Health calling for more research and a network of hospital-based clinics, many doctors still don’t know how to diagnose and manage ME/CFS and lack or research means that we still don’t have any effective forms of treatment.

Dr Charles Shepherd, the charity’s medical adviser, added: “There are major problems with both undergraduate and postgraduate medical education on ME.

“Undergraduate education on ME is inadequate, or even non-existent, in many medical schools.  So, doctors are qualifying knowing little or nothing about the diagnosis or management of ME and without ever seeing a patient with ME. This is particularly so in medical schools where there is nobody carrying out research, or a clinician seeing patients with ME.

“Continuing lack of medical education means that many doctors in primary care/general practice are then unsure about how to make a diagnosis (leading to a late or misdiagnosis) and/or being unable to provide guidance on even basic aspects of management.

“This is a completely unacceptable situation for a disease that is twice as common as multiple sclerosis and where a new report has estimated that is costing the UK economy around £3.5 billion in lost taxes, healthcare and benefit costs.”

The motion was passed unanimously:

“That this House calls on the Government to provide increased funding for biomedical research into the diagnosis and treatment of ME, supports the suspension of Graded Exercise Therapy and Cognitive Behaviour Therapy as means of treatment, supports updated training of GPs and medical professionals to ensure they are equipped with clear guidance on diagnosis of ME and appropriate management advice to reflect international consensus on best practice, and is concerned about the current trends of subjecting ME families to unjustified child protection procedures.”


Comment on the Debate

Dr Charles Shepherd, Hon. Medical Adviser, ME Association

“Overall, I thought it was an excellent debate and although the House of Commons chamber looked rather empty at times, it is quite an achievement to get around 40 MPs to attend a backbench chamber debate for 90 minutes at the end of Thursday afternoon – when most are heading home to their constituencies.

“Carol Monaghan made an excellent opening speech which was followed by shorter speeches from over 20 MPs.

“MPs from all political parties made very similar points covering all the key concerns that have been put to them by the Forward ME Group in our briefing document – lack of medical education, need for biomedical research, NICE recommendations on CBT and GET, the PACE trial etc.

“Most MPs also referred to personal issues that had been raised by their constituents – some of which very clearly illustrated the need for an urgent change of attitude by some sections of the medical profession.

“A number of MPs made very thoughtful contributions (e.g. Nicky Morgan, Ben Lake, David Drew, Dr Phillipa Whitford) and others spoke with real passion (e.g. Stephen Pound).

“And while ministerial responses tend to be disappointing when it comes to actual action, I think that Steve Brine, Minister for Health, had clearly got the message about education, lack of biomedical research, bad management etc and that he will be talking to his advisers and colleagues about the points that were being made.

“One specific ministerial action, which is clearly going to happen, is a meeting with the President of the Royal College of General Practitioners to discuss GP education – which can obviously follow up the work that the Forward Group have been doing with the RCGP.

“So, a big thank you to Carol for securing this debate; thanks to all the MPs who turned up and spoke, and thanks to everyone who wrote to their MP to ask them to attend.

List of MPs who took part in the debate – in order of speaking:

1.      Carol Monaghan – SNP – Glasgow NW 2.      Ben Lake – Plaid Cymru – Ceredigion
3.      Sir David Amess – Con – Basildon 4.      Liz Twist – Lab – Blaydon
5.      Adrian Bailey – Lab – West Bromwich 6.      Nick Symonds – Lab – Torteen (Wales)
7.      Nicky Morgan – Con – Loughborough 8.      Liz McInnes – Lab – Haywd & Middleton
9.      Kevin Foster – Con – Torbay 10.   Patricia Gibson – SNP – Ayrshire & Arran
11.   Emma Lewell-Buck – Lab – South Shields 12.   Darren Jones – Lab – Bristol North West
13.   David Drew – Lab – Stroud 14.   Mohammed Yasin – Lab – Bedford
15.   Stephen Kerr – Con – Stirling 16.   Jim Shannon – DUP – Strangford
17.   Kelvin Hopkins – Ind – Luton North 18.   Dr Phillipa Whitford – SNP Health
19.   Stephen Pound – Lab – Ealing North 20.   Sharon Hodgson – Shadow Health
21.   Karen Lee – Lab – Lincoln 22.   Steve Brine – Health Minister
23.   Carol Monaghan – Concluding remarks

A number of other MPs – Justine Greening, Con, Putney, Julian Lewis, Con, New Forest East, Paula Sherrif, Lab, Dewsbury – made interventions. NB:  There were other MPs in the chamber for all or part of the debate but did not take part. See Hansard Volume 653.

Chronic fatigue syndrome in the emergency department

Abstract:

PURPOSE: Chronic fatigue syndrome (CFS) is a debilitating disease characterized by fatigue, postexertional malaise, cognitive dysfunction, sleep disturbances, and widespread pain. A pilot, online survey was used to determine the common presentations of CFS patients in the emergency department (ED) and attitudes about their encounters.

METHODS: The anonymous survey was created to score the severity of core CFS symptoms, reasons for going to the ED, and Likert scales to grade attitudes and impressions of care. Open text fields were qualitatively categorized to determine common themes about encounters.

RESULTS: Fifty-nine percent of respondents with physician-diagnosed CFS (total n=282) had gone to an ED. One-third of ED presentations were consistent with orthostatic intolerance; 42% of participants were dismissed as having psychosomatic complaints. ED staff were not knowledgeable about CFS. Encounters were unfavorable (3.6 on 10-point scale). The remaining 41% of subjects did not go to ED, stating nothing could be done or they would not be taken seriously. CFS subjects can be identified by a CFS questionnaire and the prolonged presence (>6 months) of unremitting fatigue, cognitive, sleep, and postexertional malaise problems.

CONCLUSION: This is the first investigation of the presentation of CFS in the ED and indicates the importance of orthostatic intolerance as the most frequent acute cause for a visit. The self-report CFS questionnaire may be useful as a screening instrument in the ED. Education of ED staff about modern concepts of CFS is necessary to improve patient and staff satisfaction. Guidance is provided for the diagnosis and treatment of CFS in these challenging encounters.

Source: Timbol CR, Baraniuk JN. Chronic fatigue syndrome in the emergency department. Open Access Emerg Med. 2019 Jan 11;11:15-28. doi: 10.2147/OAEM.S176843. eCollection 2019.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6333158/ (Full article)

Perceptions of chronic fatigue syndrome in the emergency department

Press release: January 10, 2019, Georgetown University Medical Center. Findings from a novel online questionnaire of people with chronic fatigue syndrome (CFS) who rated their perceptions of care in a hospital’s emergency department suggest the majority of these patients do not receive proper care, say researchers from Georgetown University Medical Center.

The study, published in the journal Open Access Emergency Medicine, is the first known investigation of the presentation of CFS in the emergency department (ED). The findings highlight a profound lack of understanding of CFS by health care workers, says the study’s senior investigator, allergist and immunologist James N. Baraniuk, MD, a professor of medicine at Georgetown who treats people with CFS.

He says two-thirds of respondents report they either would not go to an ED because they believed they wouldn’t be taken seriously, or had previous unsatisfactory experiences. Only a third of patients in the survey said they received appropriate treatment in the ED.

“The high proportion of patients who were basically told ‘It is all in your head’ by ED staff indicates that there is much misunderstanding and misgivings about the diagnosis of CFS. These patients should feel they are respected and that they can receive thorough care when they feel sick enough to go to an ED,” he says.

Baraniuk says more training is needed for ED staff and physicians to better understand the disorder.

The 282 participants in the survey all had physician-diagnosed CFS. Participants were predominantly women (87 percent), educated (70 percent had at least a college degree), and had a primary care physician (93 percent).

From the survey, researchers determined that:

Only 59 percent of CFS patients had gone to an ED. In this group, 42 percent were dismissed as having psychosomatic complaints.

33 percent had symptoms consistent with a condition known as orthostatic intolerance, which occurs when a person feels faint when standing or sitting upright because not enough blood is reaching the brain and heart. The symptoms only improve when a person lies down.

CFS patients who went to the ED collectively rated caregivers’ knowledge about CFS at 3.6 on a 10-point scale.

41 percent of CFS respondents did not go to the ED when ill because they felt nothing could be done or they would not be taken seriously.

“An already-available CFS Symptom Severity Questionnaire can be used in the ED to assist with the diagnosis of CFS, and to differentiate exacerbations of CFS symptoms from medical emergencies such as heart attacks or infections,” Baraniuk says.

The number one reason for going to the ED was orthostatic intolerance.

“This is of importance because it provides a starting point for diagnosis and treatment by ED physicians,” Baraniuk says. “This condition is something that can be readily addressed by ED caregivers. There is a real need for physician education that will improve their efficiency in identifying and treating CFS and in distinguishing CFS symptoms from other diseases in the exam room.”

“We found that intolerance of exercise and intolerance to alcohol consumption were common to those diagnosed with CFS so this may help distinguish CFS from other conditions,” says study co-author Christian R. Timbol, MD, who worked with Baraniuk as a medical student before becoming an emergency medicine resident physician at Thomas Jefferson University Hospital in Philadelphia.

Chronic fatigue syndrome affects between 836,000 and 2.5 million Americans, according to a National Academy of Medicine review of over 9,000 articles covering 64 years of research.

This reviewers renamed the syndrome “Systemic Exertion Intolerance Disease” to emphasize the disability, post exertional malaise or exhaustion that follows mild exertion, cognitive dysfunction and orthostatic intolerance (blood pressure and heart rate changes that cause dizziness) that are the salient features of the illness.

Journal Reference: Christian Timbol, James Baraniuk. Chronic fatigue syndrome in the emergency department. Open Access Emergency Medicine, 2019; Volume 11: 15 DOI: 10.2147/OAEM.S176843 https://www.dovepress.com/chronic-fatigue-syndrome-in-the-emergency-department-peer-reviewed-article-OAEM

Are ME/CFS Patient Organizations “Militant”?

Abstract:

Myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS) is a contested illness category. This paper investigates the common claim that patients with ME/CFS—and by extension, ME/CFS patient organizations (POs)—exhibit “militant” social and political tendencies. The paper opens with a history of the protracted scientific disagreement over ME/CFS. We observe that ME/CFS POs, medical doctors, and medical researchers exhibit clear differences in opinion over how to conceptualize this illness.

However, we identify a common trope in the discourse over ME/CFS: the claim of “militant” patient activism. Scrutinizing this charge, we find no compelling evidence that the vast majority of patients with ME/CFS, or the POs representing them, have adopted any such militant political policies or behaviours. Instead, we observe key strategic similarities between ME/CFS POs in the United Kingdom and the AIDs activist organizations of the mid-1980s in the United States which sought to engage scientists using the platform of public activism and via scientific publications.

Finally, we explore the contours of disagreement between POs and the medical community by drawing on the concept of epistemic injustice. We find that widespread negative stereotyping of patients and the marginalization and exclusion of patient voices by medical authorities provides a better explanation for expressions of frustration among patients with ME/CFS.

Source: Blease, C. & Geraghty, K.J. Are ME/CFS Patient Organizations “Militant”? Bioethical Inquiry (2018). https://doi.org/10.1007/s11673-018-9866-5

Myalgic encephalomyelitis/chronic fatigue syndrome and the biopsychosocial model: a review of patient harm and distress in the medical encounter

Methods: A narrative review methodology is employed to synthesize the evidence for potential iatrogenesis.

Results: We identify seven potential modalities of iatrogenesis or harm reported by patients:

  1. difficulties in reaching an acceptable diagnosis;

  2. misdiagnosis, including of other medical and psychological conditions;

  3. difficulties in accessing the sick role, medical care and social support;

  4. high levels of patient dissatisfaction with the quality of medical care;

  5. negative responses to controversial therapies (cognitive behavioral therapy and graded exercise therapy);

  6. challenges to the patient narrative and experience;

  7. psychological harm (individual and collective distress).

Conclusion: The biopsychosocial framework currently applied to ME/CFS is too narrow in focus and fails to adequately incorporate the patient narrative. Misdiagnosis, conflict, and harm are observable outcomes where doctors’ and patients’ perspectives remain incongruent. Biopsychosocial practices should be scrutinized for potential harms. Clinicians should consider adopting alternative patient-centred approaches.

  • Implications for rehabilitation
  • Patients with ME/CFS may report or experience one or more of the modalities of harms and distress identified in this review.

  • It is important health and rehabilitation professionals seek to avoid and minimize harms when treating or assisting ME/CFS patients.

  • There are conflicting models of ME/CFS; we highlight two divergent models, a biopsychosocial model and a biomedical model that is preferred by patients.

  • The ‘biopsychosocial framework’ applied in clinical practice promotes treatments such as cognitive behavioral therapy and exercise therapy, however, the evidence for their success is contested and many patients reject the notion their illness is perpetuated by dysfunctional beliefs, personality traits, or behaviors.

  • Health professionals may avoid conflict and harm causation in ME/CFS by adopting more concordant ‘patient-centred’ approaches that give greater prominence to the patient narrative and experience of illness.

SourceKeith J. Geraghty & Charlotte Blease (2018) Myalgic encephalomyelitis/chronic fatigue syndrome and the biopsychosocial model: a review of patient harm and distress in the medical encounter, Disability and Rehabilitation, DOI: 10.1080/09638288.2018.1481149

Chronic fatigue syndrome: The male disorder that became a female disorder

Previously long-term fatigue was considered a male disorder caused by societal pressures. Today women comprise the majority of ME patients, and they feel that their condition is their own fault.

Throughout history some people have suffered from a lack of energy and long-term, physical fatigue. Today these symptoms are classified as myalgic encephalomyelitis (ME) or chronic fatigue syndrome (CFS).

It is commonly thought that chronic fatigue has mainly psychological causes and that it affects perfectionistic women who cannot live up to their own unreasonably high standards.

This has not always been the case. Just over 100 years ago it was primarily upper class men in intellectual professions who were affected. “Neurasthenia,” as the condition was called at the time, was a physical diagnosis with high status.

No longer legitimate

“The medical understanding of long-term fatigue has changed. Previously the condition was viewed as a typically male disorder; now it is perceived as a typically female disorder. The diagnosis of neurasthenia, which has a male connotation, was changed to the ME diagnosis, which has a female connotation,” explains Olaug S. Lian, a sociologist and professor at UiT The Arctic University of Norway.

Together with Hilde Bondevik of the University of Oslo, Lian has studied how the view of women and perceptions of the body, gender and femininity in two different historical periods have been manifested in the medical understanding of long-term chronic fatigue.

“Long-term fatigue was viewed as a legitimate disorder, a result of the heroic efforts of the upper class male. Today, it is a stigmatizing disorder, understood as an expression of women’s lack of ability to cope with their lives, a kind of breach of character,” says Lian.

Not only has the fatigued patient changed gender. Previously doctors believed that long-term fatigue was a neurological, physical disorder, while today it is categorized primarily as psychological in nature. And while in the past, society was thought to be the cause of the disorder, today the individual is supposedly to blame.

What happened to cause this change?

Upper class diagnosis

At the end of the 1800s neurasthenia was the most widespread diagnosis for long-term fatigue. Neurologists believed the condition was caused by a physical, neurological disease that affected the entire body, causing intense, long-term fatigue.

Although women were also diagnosed with the disorder, the typical patient was a man, and not just any kind of man. He was “civilized, refined, and educated, rather than of the barbarous and low-born and untrained,” according to neurologist George Beard.

Society was to blame

Doctors at the time believed that the cause of the disorder could be found in a rapidly changing society — urbanization, industrialization and women’s entry into working life.

Quite simply, modern civilization ran roughshod over the nervous system of upper class men, who were overstimulated by too much pressure and activity and too little sleep and rest.

“It was regarded as both legitimate and understandable that even the ‘great men’ could fall apart as a result of long-term, difficult intellectual work. It was viewed as positive that the body sent signals when the burden was too great. The body was viewed as an electrical fuse box and the thinking was that it was better for one fuse to burn out rather than for the house to catch on fire,” says Lian.

Different genders, different causes

The comments about the diagnosis also revealed past understandings of biological gender differences. Women could get neurasthenia from sexual frustration, while men could get it from excessive sexual activity, including masturbation.

Moreover, there was a connection between gender and class.

“To simplify a bit, we can say that it was mainly middle class men and working class women whose diagnosis of neurasthenia was explained by overwork. For working class men it was due to sexual escapades, and for middle class women the cause given was heredity or ‘women’s issues’,” explains Lian.

The fall of neurasthenia

Neurasthenia lost its popularity as a diagnosis in the early 1900s. One reason for this was that psychiatry became a medical field in its own right.

“Psychiatry took neurasthenia with it and changed its definition from a physical to a psychological condition. Since women were regarded as psychologically weaker and therefore more disposed to mental illness, the disorder became a female problem,” says Lian.

Fight over definitions

Today ME is the most common name for the disorder, defined as long-term, intense fatigue that cannot be directly linked to a well-defined illness and that does not disappear with rest. The condition is chronic, it cannot be cured with medical treatment and there is disagreement as to the cause.

“The lack of scientifically generated findings, medical explanations and effective treatment make ME a diagnosis with low status and low legitimacy within the medical community,” says Lian.

Currently the main theory is that ME results from an inability to handle stress and that perfectionistic people — the “good girls” — are especially at risk. The debate about how ME should be understood and explained is highly polarized, between those who believe that it is an illness caused by infections or vaccination and those who believe that ME has mainly psychological causes.

“I would like to see some humility about what we actually know about the disorder and not present value judgments as facts. Doctors must also be honest and acknowledge that we have very little hard-and-fast knowledge about this condition,” states Lian.

Blame and shame

The two historical periods have almost identical depictions of the phenomenon of long-term fatigue, although the names are different. But there is one important difference: the disorder is no longer regarded as a legitimate, anticipated outcome of overwork.

“Today the medical community is searching for explanations of ME at the individual level. The ME patient is depicted as a woman with five-star goals and four-star abilities — with character traits that make it hard for them to cope with their own lives,” says Lian.

“When the entire problem is seen as the patient’s fault, the person experiences blame and shame because it is the patient, not society, who is the cause of the illness. It is therefore the individual who is responsible for coping with the illness, such as by changing her own thought patterns,” says Lian.

Wrong kind of tired

She points out that the ability to cope with one’s own life is an important value in Western culture. Mental disorders, however, are associated with weakness. The current understanding of long-term fatigue is also linked to how we think about tiredness, according to Lian.

“There are strong norms for when you are allowed to be tired and worn out and how you are supposed to show tiredness in daily life. If you have been awake all night with a sick infant, you have a good reason to be tired at work. Other reasons are less legitimate. Workplace reports of absence never state that someone is at the psychologist, while it is completely acceptable to say that someone is at the dentist.”

“Being tired for the wrong reasons is seen as a sign of weakness, which must be overcome and hidden. It is in this context that we must understand the medical theories on a lack of coping ability and the objections of ME patients to these theories,” says Lian.

She believes such norms often make ME patients feel that the psychological explanation is a burden, although doctors do not necessarily mean for it to have this affect.

“What is it about the ME debate that makes the opposing sides so obstinate?”

“The doctors and patients talk past each other. The doctors think that an ME diagnosis is value neutral, but the patient hears ‘it’s my fault that I am sick and it’s my responsible to get better’. But although most people feel that mental disorders have lower value than somatic disorders, it is not a given that the doctors do,” says Lian.

Gendered explanation disappeared?

Although about three of four people who are diagnosed with ME today are women, the explicit, biology-based gendered explanations have disappeared from the debate, according to Lian.

“This may simply be because today we put greater focus on gender equality — which makes it less legitimate to claim that women are naturally inferior to men,” says Lian.

However, she believes that the ME diagnosis embodies a view of women that has long historical roots.

“The profile of the upper class woman from the 1800s who cannot cope with pressure and stress both inside and outside the home is still with us today,” says Lian.

Cultural bias

“How can your analysis contribute to the current debate about ME?”

“We show how the medical understanding of fatigue and lack of energy is impacted by the norms and values of society at large, for example, that medical knowledge reflects the view of women in our culture. Norms and values combine with biomedical knowledge in a way that makes it difficult to see what is what,” says Lian.

 

Source: KILDEN – Information Centre for Gender Research in Norway. (2014, February 20). Chronic fatigue syndrome: The male disorder that became a female disorder. ScienceDaily. Retrieved March 4, 2017 from https://www.sciencedaily.com/releases/2014/02/140220083145.htm

 

Epistemic injustice in healthcare encounters: evidence from chronic fatigue syndrome

Abstract:

Chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) remains a controversial illness category. This paper surveys the state of knowledge and attitudes about this illness and proposes that epistemic concerns about the testimonial credibility of patients can be articulated using Miranda Fricker’s concept of epistemic injustice. While there is consensus within mainstream medical guidelines that there is no known cause of CFS/ME, there is continued debate about how best to conceive of CFS/ME, including disagreement about how to interpret clinical studies of treatments.

Against this background, robust qualitative and quantitative research from a range of countries has found that many doctors (and medical students) display uncertainty about whether CFS/ME is real, which may result in delays in diagnosis and treatment for patients. Strikingly, qualitative research evinces that patients with CFS/ME often experience suspicion by healthcare professionals, and many patients vocally oppose the effectiveness, and the conceptualisation, of their illness as psychologically treatable.

We address the intersection of these issues and healthcare ethics, and claim that this state of affairs can be explained as a case of epistemic injustice (2007). We find evidence that healthcare consultations are fora where patients with CFS/ME may be particularly vulnerable to epistemic injustice. We argue that the (often unintentional) marginalisation of many patients is a professional failure that may lead to further ethical and practical consequences both for progressive research into CFS/ME, and for ethical care and delivery of current treatments among individuals suffering from this debilitating illness.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

 

Source: Blease C, Carel H, Geraghty K. Epistemic injustice in healthcare encounters: evidence from chronic fatigue syndrome. J Med Ethics. 2016 Dec 5. pii: medethics-2016-103691. doi: 10.1136/medethics-2016-103691. [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/27920164

 

Working with uncertainty: A grounded theory study of health-care professionals’ experiences of working with children and adolescents with chronic fatigue syndrome

Abstract:

This grounded theory study explores conceptualisations of chronic fatigue syndrome/myalgic encephalomyelitis from semi-structured interviews with 10 health-care professionals working with children and adolescents. The findings suggest that a lack of a clear empirical understanding of chronic fatigue syndrome/myalgic encephalomyelitis leads to ‘working with uncertainty’, whereby health-care professionals utilise previous experiences to make sense of the condition and inform their clinical practice. How health-care professionals make sense of chronic fatigue syndrome/myalgic encephalomyelitis may influence the labels given to young people and the interventions they receive. The findings provide insight into a currently understudied area, and highlight potential avenues for further research and clinical practice.

© The Author(s) 2015.

 

Source: Marks MR, Huws JC, Whitehead L. Working with uncertainty: A grounded theory study of health-care professionals’ experiences of working with children and adolescents with chronic fatigue syndrome. J Health Psychol. 2015 May 8. pii: 1359105315583367. [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/25957226