In 1977 George Engel wrote about the need for an ‘integrated approach’ in medicine that moved the focus beyond biological mechanisms of disease to include all pertinent aspects of illness presentation, setting out a ‘biopsychosocial model’.1
Around the same time, McEvedy and Beard asserted that the disease ‘benign myalgic encephalomyelitis’, described by Ramsay at the Royal Free Hospital, London, was nothing more than a case of ‘mass hysteria’.2 In the 1980s, doctors combined theories of neurasthenia, hysteria, and somatoform illness, to reconstitute ME as ‘chronic fatigue syndrome’. Psychiatrists argued that CFS was best understood using a biopsychosocial (BPS) framework, being perhaps triggered by viral illness (biology), but maintained by certain personality traits (psychology) and social conditions (sociology).3
Although the BPS model holds much utility in understanding ‘illness’ in a wider context, many sufferers of CFS reject the notion that their illness is psychologically or socially derived. Significant numbers of patients report difficult interactions with doctors that leave them feeling dissatisfied, disbelieved, and distressed.
In this article, we question whether or not the BPS model generates ‘harms’ for CFS patients, and we ask if other, alternative approaches might be more preferable to both patients and GPs…
CONCLUSION: INVOLVING PATIENTS AND EMPOWERING GPS
Many CFS patients report that they wish to be cared for by GPs in primary care, rather than psychiatrists in specialist centres.
CFS patients ranked the professionals they want to manage their condition, putting GPs as first choice (1502 votes), with psychiatrists last choice (15 votes).10 However, in a survey of attitudes to CFS among English GPs, Bowen and colleagues found that many GPs lack confidence in making a diagnosis (48%) or in treating patients (41%).13
Scepticism and a lack of awareness and training among GPs concerning CFS may well explain some of the patient dissatisfaction highlighted in patient surveys, as well as explain delays and error in diagnosis. However, it is also arguable that the biopsychosocial approach of challenging the nature of the illness, and seeking to intervene with psychotherapy to challenge patients’ illness beliefs may also play a part in generating distress for patients with CFS.
In order to minimise iatrogenesis, GPs require better training in how to diagnose CFS and communicate with patients with CFS; GPs should not seek to impose a biopsychosocial model of illness on a patient. Models of illness should not supplant the ‘lived experience of illness’ or subjugate the expert status of the patient as ‘witness to their condition’. Nassir Ghaemi, critical of the biopsychosocial model, suggests doctors should consider alternative clinical approaches, such as Karl Jaspers’ ‘method-based’ or William Olsen’s ‘medical humanist’ model’.14
Such models might be used by GPs to:
- inform patients of the absence of known aetiology in CFS (rather than speculating around psychogenic causes);
- inform patients that there are explanations for some CFS symptoms (for example, the IOM report of biomedical evidence);
- offer patients treatments such as CBT, but inform patients that these therapies do not work for all (rather than suggesting the patient controls outcomes);
- offer alternative interventions and support, such as counselling and community care (rather than just referral to CFS clinics); and
- accept the legitimacy of the patient account (rather than seeking to challenge patients’ illness beliefs).
Such differences of approach may seem subtle, but arguably represent a more pragmatic approach, which we recommend for general practice. It is probable that harm could be minimised by adopting a more concordant model that includes patients’ preferences in treatment and management.
Chronic fatigue syndrome: is the biopsychosocial model responsible for patient dissatisfaction and harm?, by Keith J Geraghty & Eneesz Esmail, in British Journal of General Practice vol. 66 no. 649 437-438 [Published 1 August 2016]