The findings sounded like good news. As reported recently in The Lancet, chronic fatigue syndrome (CFS) may be successfully treated with a combination of psychotherapy and exercise. Specifically, results of a randomized trial showed that cognitive-behavioral therapy and graded exercise therapy have a moderate effect in the treatment of CFS.1
Yet a report in The New York Times2 suggested that the study results “. . . are certain to displease many patients and to intensify a fierce, long-running debate about what causes the illness and how to treat it.” The Times noted that “many patients . . . believe the syndrome may be caused by viruses related to mouse leukemia viruses, and they are clamoring for access to antiretroviral drugs. . . .” Furthermore, “. . . the new study . . . is expected to lend ammunition to those who think the disease is primarily psychological or related to stress [italics added].”2
For those of us accustomed to the charge that psychiatry is trying to “medicalize normality”—and that “psychiatry has no objective tests” to validate our disease categories—this report is both ironic and revealing. First, it suggests that patients—not just physicians—may sometimes have compelling reasons for applying the “medical model” to conditions whose etiology and pathophysiology remain controversial and obscure. Indeed, in light of the serious adverse effects associated with antiretroviral drugs, it is extraordinary that some patients would be clamoring for these agents, given the tenuous link between CFS and a viral etiology. I suspect this speaks to the profound lethargy and physical impairment experienced by some patients with severe forms of CFS—and this, in turn, speaks to an important truth regarding the nature of what we call disease. “Disease” (disease) is usually first recognized by those who suffer with it, and by their loved ones. It is not fundamentally a scientific term, but an experiential concept born of the human condition.3 Those who suffer with CFS understand this, and their predicament serves as a window into the conceptual and semantic problems that bedevil psychiatry.
Indeed, the Times report by David Tuller presents a microcosm of the linguistic ferment in the realm of medical nosology. Note that the reporter uses 3 different terms to describe CFS: illness, syndrome, and disease. This alone should tell us that in the matter of describing and classifying abnormal physical and emotional states, confusion abounds—and not just among journalists. Physicians and researchers, too, often bandy about terms such as “illness,” “syndrome,” and “disease” without much reflection as to the precise meaning of these terms, or how they differ from one another.
The Platonic enterprise of “carving Nature at its joints” is wasted surgery, if we are not relieving the suffering and incapacity of our patients.
It is notable that despite a lack of reliable biomarkers or “lab tests” for CFS, the CDC describes CFS as a “distinct disorder with specific symptoms and physical signs.”4 Here we meet yet another poorly defined term: disorder—the term of choice for conditions in the DSMs, and one that strikes some of us as a bit of a dodge. How, after all, does a disorder differ from a disease? If it is simply a matter of identifiable pathophysiology, then why is Alzheimer disease listed as a cognitive “disorder” in DSM-IV? Are we to infer that all “diseases” are also “disorders,” but that the converse is not true? It is enough to make the clinician’s eyes glaze over.
It is not merely intellectual laziness that underlies this unsavory stew of disease terms, although some-times that charge may apply. In truth, we physicians are, by and large, practical folk. We see our waiting rooms crowded with fellow human beings in various states of pain, suffering, and incapacity. We want to help them as efficiently and effectively as possible, and we don’t care very much, at the end of the day, whether we have alleviated a syndrome, an illness, a disease, or a disorder—and neither does the patient. We do care a great deal that the patient who came in feeling miserable leaves feeling better. We engage in a daily struggle to reduce the net amount of medical suffering and incapacity in the world—not to win prizes as philosophers of science or language.
Unfortunately, in recent years, some scholars and researchers have been fixated on the precise boundaries of mental “normality” and “abnormality”—as if Nature itself recognizes this neat dichotomy! To be sure, many of us—including this writer—have pointed to instances in which a condition has been prematurely or inappropriately labeled a “mental disorder.” For example, I have argued against including conditions such as “pathological bigotry” and “Internet addiction” in DSM-5, and I have raised serious questions regarding the validity of so-called hypoactive sexual desire disorder.5-7 Others have gone much further in their critique of psychiatric nosology, declaring some psychiatrists guilty of “disease-mongering” or pointing to the danger of diagnostic “fads” in psychiatry.8,9 (Recently, Dr Allen Frances directed me to an uproarious YouTube video, discussing the medical treatment of “excessive and annoying cheerfulness!”10)
1. White PD, Goldsmith KA, Johnson AL, et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet. 2011;377:823-836.
2. Tuller D. Researchers say psychotherapy eases chronic fatigue, a finding unlikely to satisfy. New York Times. February 17, 2011. http://www.nytimes.com/2011/02/18/health/research/18fatigue.html?_r=1. Accessed March 12, 2011.
3. Pies R. What should count as a mental disorder in DSM-5? Psychiatric Times. April 14, 2009. http://www.psychiatrictimes.com/dissociative-identity/content/article/10168/1402032. Accessed March 12, 2011.
4. Pubmed Health. Chronic Fatigue Syndrome. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002836.
5. Pies R. Is bigotry a mental illness? Psychiatric Times. May 1, 2007. http://www.psychiatrictimes.com/display/article/10168/55226. Accessed March 12, 2011.
6. Pies R. Should DSM-V designate “internet addiction” a mental disorder? Psychiatry. (Edgemont). 2009;6:31-37. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719452. Accessed March 12, 2011.
7. Pies RW. FDA lacks desire for flibanserin—but does hypoactive sexual desire disorder even exist? Psychiatric Times. August 4, 2010. http://www.psychiatrictimes.com/sexual-disorders/content/article/10168/1632801. Accessed March 12, 2011.
8. Healy D. The latest mania: selling bipolar dis-order. PLoS Med. 2006;3:e185. doi:10.1371/journal.pmed.0030185. http://www.plosmedicine.org/article/metrics/info%3Adoi%2F10.1371%2Fjourn.... Accessed March 12, 2011.
9. Frances A. Normality is an endangered species: psychiatric fads and overdiagnosis. Psychiatric Times. July 6, 2010. http://www.psychiatrictimes.com/dsm-5/content/article/10168/1598676. Accessed March 12, 2011.
10. FDA approves depressant drug for the annoyingly cheerful. http://www.youtube.com/watch?v=_et969pc7iA.
11. McLaren N. Temper tantrums, mental disorder, and DSM-5: the case for caution. Psychiatric Times. February 22, 2011. http://www.psychiatrictimes.com/blog/dsm-5/content/article/10168/1803237. Accessed March 12, 2011.
12. Pies R. The ideal and the real: how does psychiatry escape The DSM-5 “fly-bottle”? Bulletin of the Association for the Advancement of Philosophy and Psychiatry. 2010;17(2):18-20. http://alien.dowling.edu/~cperring/aapp/bulletin_v_17_2/Vol17N2.pdf. Accessed March 12, 2011.
13. Kendell R, Jablensky A. Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry. 2003;160:4-12.
14. Pies R. Toward a concept of instrumental validity: implications for psychiatric diagnosis. http://www.crossingdialogues.com/forthcoming_papers.htm. Accessed March 12, 2011.
15. Pies R. How to eliminate narcissism overnight: DSM-V and the death of narcissistic personality disorder. Innov Clin Neurosci. 2011;8:23-27.
16. Horwitz AV, Wakefield JC. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. New York: Oxford University Press, Inc; 2007.
17. Lamb K, Pies R, Zisook S. The bereavement exclusion for the diagnosis of major depression: to be, or not to be. Psychiatry (Edgmont). 2010;7:19-25.
For further reading
Ghaemi SN. The Concepts of Psychiatry. Baltimore: Johns Hopkins University Press; 2003.
Schwartz MA, Wiggins O. Science, humanism, and the nature of medical practice: a phenomenological view. Perspect Biol Med. 1985;28:331-366.