Are Some Patients Trying to “Medicalize” Chronic Fatigue?

Part of our preoccupation with the boundaries of normality and abnormality lies in our failure to produce “a model of mental disorder,” as Dr Niall McLaren¹¹ recently argued. Indeed, I believe psychiatry has been hobbled by the very terms now emblazoned on our DSMs: “mental” and “disorder.” Neither of these terms has been satisfactorily defined, and neither has been very helpful. I would much rather see a classification of “neuropsychiatric disease” or “brain-mediated disease.”¹² More centrally, however, I believe we have gotten lost in the “trees” of boundary issues, while failing to see the “forest” of our patients’ chief concern: the relief of their suffering and incapacity; that is, the relief of disease (disease). I believe it is from this experiential wellspring that our nosology should issue. This same reality also defines our profession’s chief ethical responsibility: namely, the relief of medically based suffering and incapacity by any safe and effective means. In short, I am arguing that our nosology must be firmly rooted in our ethical calling as physicians.

Even our diagnostic criteria should follow this ethical imperative. Thus, rather than focusing primarily on etiological validity¹³—achieved when a set of diagnostic criteria is based on an identifiable pathogenic agent or process—I believe we should be focusing on what I have called instrumental validity: the extent to which our diagnostic criteria enable us to reduce the patient’s particular type of suffering and incapacity.¹⁴ (Unlike Kendell and Jablensky,¹³ I do not draw a sharp distinction between “validity” and clinical “utility.”) We can gradually refine our prototypical disease categories, based on how well their criteria hold up in empirical studies of treatment; ie, the more the category criteria facilitate effective treatment, the higher their instrumental validity. Only secondarily should our disease categories be modified by other types of validity, such as discriminant and etiological validity (Figure).^13,14 (Discriminant validity is essentially the degree to which the criteria can identify one construct, such as “narcissism,” without demonstrating a high correlation with an unrelated construct, such as “schizotypy.”¹⁵)

So, how does all this apply to CFS and the insistence by some that patients with CFS be treated with antiretroviral drugs? It would be unfair to conclude that those advocating this position are trying to “medicalize” severe, chronic fatigue, in any pejorative sense of the term “medicalize.” On the contrary: like physicians, these advocates are, in good faith, trying to alleviate disease—and they have every right to do so, regardless of how well or poorly we understand the pathophysiology of CFS. Of course, it is an empirical question as to whether antiretroviral drugs are either safe or effective in CFS. I have serious doubts, but only clinical investigation will resolve the matter. Nonetheless, there should be no quarrel over the reality of severe CFS as an instantiation of genuine disease, just as schizophrenia and major depression constitute real disease.

In my view, psychiatrists would do well to avoid scholastic disputations over “where to draw the line” between normality and abnormality.¹⁶ (If 99 in 100 stockbrokers jump out the window after the stock market crashes, is that behavior “normal” or “abnormal”?) So, too, with our nosology. The Platonic enterprise of “carving Nature at its joints” is wasted surgery, if we are not relieving the suffering and incapacity of our patients. This applies whether we are discussing major depressive symptoms following bereavement¹⁷ or severe, chronic fatigue. The central question for both our psychiatric nosology and our medical duty is just this: how much suffering and incapacity is burdening the patient who seeks our help? If the answer is, “Quite a lot,” then our patient has bona fide disease, and it is ethically incumbent on us to provide safe and effective treatment.