Three sharp strokes (correspondence)


Abbot NC


MERGE, Perth, UK


So, doctors have a dilemma, we are told (1). Some of them are ‘uncomfortable’ when patients present with their own diagnostic labels. One strategy is to engage in ‘constructive labelling’ which in the case of chronic fatigue syndrome (CFS), involves “…treating [it] as a legitimate illness… while gradually expanding understanding of the condition to incorporate the psychological and social dimensions” (1). Yet, as implied by this opinion piece, this strategy is likely to involve some dissembling, for doctors (fed on a regular diet of articles similar to (1) deposited in the medical literature from psychosocial stables) probably believe in their hearts that CFS is not a ‘legitimate’ illness and that psychosocial dimensions are paramount. So, how can doctors be helped to move forward?

Allow me to cut this Gordian Knot with three sharp strokes from the non-psychosocial literature of the past few months alone.

First, the CMO report of 2002 — albeit without the endorsement of the group of psychosocial professionals who refused to sign up to its conclusions (2) — does, in fact, state that, “CFS/ME is a genuine condition that imposes a substantial burden on patients, carers, and families… clinicians need to apply current knowledge despite the remaining uncertainty; inaction due to ignorance or denial of the condition is not excusable” (3). Second, a recently-published review notes that, “…a growing body of literature suggests that abnormal biological processes are present in many patients, including subtle abnormalities of the CNS and of neuroendocrine regulation and chronic activation of the immune system. These abnormalities across many domains suggest that chronic fatigue syndrome is a heterogeneous condition of complex and multifactorial aetiology” (4). Last, an excellent rigorous consensus panel report (based on extensive collective clinical experience of the diagnosis and/or treatment of more than twenty thousand ME/CFS patients), published in the past few weeks, has stated that, “Research has now established the legitimacy of myalgic encephalomyelitis/chronic fatigue syndrome as a biological illness” (5).

There — the problem is solved. Clinicians need not dissemble or, if you prefer, indulge in medically-explained dissimulation in response to ‘medically-unexplained symptoms’. Instead, they can truthfully say that ME/CFS is a genuine condition for which there is mounting evidence of a physical basis, and can proceed without delay to give the appropriate care and treatment demanded by the CMO (3) for the constellation of symptoms among which pain is prominent. Simple, really — and more conducive to a genuinely healing encounter between doctor and patient.


  1. Fischhoff B, Wessely S. Managing patients with inexplicable health problems. BMJ 2003; 326: 595–7.
  2. Abbot NC, Spence VA. Unhelpful Counsel? Response to the Chief Medical Officer’s Working Group report on CFS/ME. ME Research UK analysis No. 02-M001. April 2002. Available from
  3. A report of the Chief Medical Officer’s CFS/ME working group. Department of Health. January 2002. Available from
  4. Afari N, Buchwald D. Chronic Fatigue Syndrome: A Review. Am J Psychiatry 2003; 160: 221–36.
  5. Carruthers BM, Jain AK, De Meirleir KL et al. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols. Journal of Chronic Fatigue Syndrome 2003; 11: 7–115.


British Medical Journal, 2003 Mar 18; online edition

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