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Functional illness in primary care: dysfunction versus disease

Nefyn Williams*, Clare Wilkinson, Nigel Stott and David B Menkes

BMC Family Practice 2008, 9:30  doi:10.1186/1471-2296-9-30

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Various comments

Tom Kindlon   (2009-01-16 09:34)  Irish ME/CFS Association - for Information, Support & Research email

This paper refers to using a re-attribution programme.

I thought I would highlight the results of a trial[1] published last year on the topic.

It involved testing practice-based training of GPs in reattribution. The method to test the hypothesis was a "cluster randomised controlled trial in 16 practices, 74 GPs and 141 patients with medically unexplained symptoms of 6 hours of reattribution training v. treatment as usual." It found that "Practice-based training in reattribution changed doctor-patient communication without improving outcome of patients with medically unexplained symptoms". Hardly a ringing endorsement of the method.

There has been a lot of hype about the effectiveness of Cognitive Behavioural Therapy (CBT) for Chronic Fatigue Syndrome (CFS). However, a meta-analysis[2] of its efficacy of CBT for CFS published last year might temper some of the enthusiasm. The studies involved a total of 1371 patients.

This involved calculating the size of an effect measure, the Cohen's d value.

They calculated d using the following method:

"Separate mean effect sizes were calculated for each category of outcome variable (e.g., fatigue self- rating) and for each type of outcome variable (mental, physical, and mixed mental and physical). Studies generally included multiple outcome measures. For all analyses except those that compared different categories or types of outcome variables, we used the mean effect size of all the relevant outcome variables of the study."

d was calculated to be 0.48.

For anyone unfamiliar with Cohen's d values, they are not bounded by 1; also, the higher the score, the bigger the "effect size" i.e. the more "effective" a treatment was found to be. Cohen's d values are considered to be a small effect size at 0.2, a moderate effect size at 0.5, and a large effect size at 0.8[2].

There are now hundreds of studies that have found "physical" abnormalities of one sort or another in Chronic Fatigue Syndrome. Thus I question the placement of "Chronic Fatigue" (which many/most people would read as referring to Chronic Fatigue Syndrome as it is listed beside Fibromyalgia and Irritable Bowel Syndrome) in figure 1, "Hypothetical scatter plot of dysfunction versus pathology in primary care consultations" where "evidence of pathological change" is said to be "absent". The numerous abnormalities found raise questions about the placement on the scatter plot or else the limitations of the concept. Also how "reversible" the "abnormal functioning, either physiological or psychological" is, remains far from clear given the low recovery rates.

[1] Morriss R, Dowrick C, Salmon P, Peters S, Dunn G, Rogers A, Lewis B, Charles-Jones H, Hogg J, Clifford R, Rigby C, Gask L. Cluster randomised controlled trial of training practices in reattribution for medically unexplained symptoms. Br J Psychiatry. 2007 Dec;191:536-42

[2] Malouff, J. M., et al., Efficacy of cognitive behavioral therapy for chronic fatigue syndrome: A meta-analysis. Clinical Psychology Review (2007), doi:10.1016/j.cpr.2007.10.004

[3] Cohen J: Statistical power analysis for the behavioural sciences. Edited by: 2. New Jersey: Lawrence Erlbaum; 1988.

Competing interests

No competing interests


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