Psychiatrists Reject Either/Or Approach

Psychiatrists expressed dismay about the either/or argument that dominates discussion of CFS: Either it is a medical disease or it is a psychiatric disorder.

Ian Hickie said psychiatrists, by being openly dismissive of CFS, have been interpreted as saying there's nothing wrong with these people. Meanwhile, people in the CFS community want to have nothing to do with psychiatry, arguing it has nothing to offer. In fact, he said, while fatigue exists independently of psychiatric disorders and appears to have its own genetic and environmental determinants, there are overlaps and relationships between fatigue states and psychiatric disorders that need to be understood so that effective treatments can develop.

Michael Sharpe said it is unfortunate that the societal stigma against psychiatric illness makes it difficult for CFS patients to take advantage of the treatments that might be helpful to them following an appropriate psychiatric evaluation. He suggested that making a specific psychiatric diagnosis may not be helpful; rather, the question should be what psychiatry has to offer CFS patients in terms of treatment.

Leonard Jason noted that the lack of practical definitions for some of the overlapping criteria between CFS and depression, coupled with misapplication of psychiatric assessment tools and the desire to establish higher prevalence rates for the illness, serve to complicate understanding of the illness.

Dr. Gurwitt denounces automatic psychiatric referrals

"Why this morbid, tiresome and destructive preoccupation with ferreting out any shred of evidence of psychiatric difficulties?"

Alan Gurwitt, a child psychiatrist, began the psychiatric morbidity session with an impassioned call to doctors to give up their "morbid fascination with psychiatric illness." He described a patient, a young medical student, who he said clearly had no previous or concurrent psychiatric condition but nevertheless was referred to him for evaluation. She was afraid that simply having the evaluation would affect her career, and it made her feel ashamed of her illness.

"There should be no reason for shame at all," Gurwitt said. "Shame related to this illness is, in part, caused by the medical community itself."

The patient’s primary care physician should be quite capable of taking a careful psychosocial history that would have revealed a great deal of useful information about the patient, and Gurwitt said he found the "too ready tendency" to refer patients to psychiatrists distressing.

"The existence of a pre-illness psychiatric condition may or may not have anything to do with the onset or course of CFIDS. There are times when such a psychiatric evaluation is valid, helpful, useful, but to do it automatically as if it’s a routine part of the assessment is completely wrong.

"When there is so much accumulating evidence--good science by good scientists, as we have witnessed at this conference--when there is so much that is being learned and so much that tells us there is a biological illness going on, and when these biological factors cannot at all be explained by psychiatric conditions, whether they exist or not, then we have to ask: Why this morbid, tiresome and destructive preoccupation with ferreting out any shred of evidence of psychiatric difficulties?

"Would not the all too limited research funds better be devoted to furthering biological research already in progress or waiting to be funded, or devoted to developing ways to improve physician interest and education?

"Psychiatrists and child psychologists do have something to contribute diagnostically and therapeutically, and we’ve heard some very good reports from them, but not by lending themselves to flawed research techniques and unfounded biases. We need to move away from what seems to be an unwritten edict that a psychiatric evaluation should always be part of the diagnostic work-up. No, no, no! Only when there are very good diagnostic and therapeutic reasons and only when the physician and the patient have a good working relationship so that a possible referral does not act to shame, to embarrass and symbolically abandon the patient."