From:

Malcolm Hooper

Emeritus Professor of Medicinal Chemistry

School of Sciences

Fleming Building

University of Sunderland

SUNDERLAND SR2 7EE 

Telephone  0191 515  2501

Fax  0191 515  2502 

Public Relations Office  0191 616  2691                         

The Deputy Editor

British Journal of General Practice         

Royal College

of General Practitioners

14 Princes Gate, 

Hyde Park London

SW7  1PU          

21st June 2002

BY FAX  to  0207 584 6716                                                                   

5 pages in total                                                                

FOR PUBLICATION        

Sir 

The Editorial by Stanley, Salmon and Peters in the May issue of the British Journal  of  General Practice  (Doctors and social epidemics: the problem of persistent unexplained physical symptoms, including chronic fatigue) appears to amount to a mass diagnosis by distance, whilst the notion that CFS/ME is created by doctors themselves has little to do with evidence-based medicine in the 21st century.

 The authors seem to have fallen into a common trap for the unwary in that they have equated chronic fatigue with the ICD-classified chronic fatigue syndrome (ME), the exact error for which JAMA was forced to issue a correction as long ago as 1990 (1). 

As far as CFS/ME is concerned, far from welcoming the belated public acceptance of what in reality has been officially recognised by the UK Department of Health and the BMA since 1988, the authors seem to resent the CMO’s acknowledgment that it is a “real” disease.  They make not a single mention of any of the mounting number of biomarkers of organic pathology which have been demonstrated worldwide in these patients and reported not only in the international literature since 1988 from no less an august body than the NIH itself (2) but also at countless international symposia such as the one at the University of Cambridge in April 1990 (where speakers included a Nobel prize nominee for medicine); the world-acclaimed Congresses held in Brussels in November 1995 and September 1999; the major international meeting hosted by The Alison Hunter Memorial Foundation in Australia in December 2001 and the many bi-annual American Association of CFS International Research and Clinical Conferences.

Could the authors be invited to explain why they ignore all the evidence which is not consistent with their own (psychiatric) model of unexplained physical illness? Misunderstood diseases have a long history in medicine and seemingly the authors of the May Editorial have failed to learn from past experience which shows that many conditions for which medical science did not have an explanation were first claimed to be psychiatric, for example within our lifetime, MS used to be called hysterical paralysis; in the 1940s  Parkinsons Disease was said by prominent psychiatrists of the time to be due to the desire in the moralistic man to masturbate (the intention tremor supposedly due to a conflict between “ an aggressive drive towards action and an equally strong internal pressure to inhibit action:  this conflict results in tremor” (3); asthma was said to be 100% psychological and before the discovery of Helicobacter, gastric ulcers used to be ascribed to an anxious personality. 

We should consider the anguish which must have been caused to sufferers of those disorders by the paternalistic certainty of the medical fraternity which abounded at those times and we must ensure that similar damage is not perpetrated on the present generation of sufferers from medically unexplained syndromes.

It seems to be a retrograde step to encourage GPs to rely on the psychiatrists’ most cost-effective tool, namely their propensity to pronounce, unchallenged, on any currently unexplained medical disorder without the need for scientific proof. Whilst admittedly the authors are writing in a British journal, they do not attempt to explain how their “social epidemics” of physical symptoms have come to affect hundreds of thousands of people worldwide who manifest exactly the same physical symptoms when such patients do not even speak the same language, for instance sufferers are to be found in Holland, Japan, Italy and Scandinavia and not only in the English speaking world and the symptoms embrace the major systems of the body, particularly the nervous system (central, autonomic and peripheral), cardiovascular, immune, musculo-skeletal and endocrine.  Fatigue is not the most prominent feature, which is post-exertional exhaustion and incapacity. 

In relation to Gulf War syndrome, a very recent presentation on 19th June 2002 in the House of Lords by Professor Robert Haley from the US summarised the conclusions from his extensive publications which showed considerable damage to the deep silent areas of the brain, particularly the right and left basal ganglia, the thalamus and the brain stem. 

The overwhelming conclusion by American experts and British scientists who also presented evidence is that Gulf War syndrome is the result of multiple exposures to multiple chemical and biological toxins; repeatedly the conviction was expressed that finding the pathoaetiology of GWS will provide essential and new understanding of PUPS (persistent unexplained physical symptoms); MUPS (multiple unexplained physical symptoms); SSIDC (signs and symptoms of ill-defined conditions) and syndromes of uncertain origin (in the latest edition of the Merck manual), included amongst which is CFS/ME and multiple chemical sensitivity (MCS). Contrary to the assertions of Stanley et al, there are no gains whatever for those with PUPS and their suffering is immense; the reality is that, far from sufferers adopting the role of victim,  it is overbearing medical practitioners who victimise these patients.

Anyone who relies, as Stanley et al do, on the surmising of a much-criticised American Assistant Professor of English (who equates CFS/ME and GWS with abduction by aliens) as scientific evidence to support their own theories must be at something of a loss in the field of neuroendocrineimmunology. 

The real criticism of the CMO’s report on CFS/ME is that it specifically advises clinicians that the very investigations (ie. immunological assays and nuclear medicine imaging) which are delivering hard evidence of organic pathology in CFS/ME are neither necessary nor appropriate for these patients.  That is a matter for concern.

In our opinion, Stanley et al have publicly exposed their own biased and limited approach to these problems and their own failure to get to grips with one of the most complex areas of medicine; in this they are not alone, because certain UK psychiatrists whose work is so often funded by charities and trusts linked to commercial interests seem to have the same problem. Outside the UK there is considerably less support for the ideas expressed in your May Editorial. 

We are able to supply copies of our recent booklet  What is ME?  What is CFS?Information for Clinicians and Lawyers” (December 2001) which provides extensive references for the organic basis of CFS/ME. 

EP Marshall

M Williams

M Hooper    

References 

(1)  AMA News Release July 1990 (AMA Science News Editor: John Hammarley)

(2)  Allergy and the chronic fatigue syndrome.    Stephen E Straus et al   J Allergy      Clin Immunol 1988:81:791-795

(3)  Psychodynamics in Parkinsonism.  Booth G.  Psychosom Med 1948:10:1-14