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Tuesday, 20 January 2004
continuing from Jan 19
page1 Jan17, page2 Jan18, page3 jan19

Quotations from the published works of Professor Simon Wessely on


Postviral fatigue syndrome: time for a new approach. David AS,
Wessely S, Pelosi AJ
BMJ 1988:296:696-699

"Future investigations and clinical practice must take into account
the similarities between the symptomatology of the post-viral
fatigue syndrome and that of common psychiatric disorders in the


What your patients may be reading. Wessely S. BMJ 1989:298:1532-

"Beard and Mitchell have returned to obscurity, but their disease
(neurasthenia) is back with a vengeance. My local bookshop has just
given ME the final seal of approval, its own shelf. A little more
psychology and a little less T-cells would be welcome".


Management of chronic (post-viral) fatigue syndrome. Simon Wessely,
Anthony David, Sue Butler, Trudie Chalder. Journal of the
Royal College of General Practitioners 1989:39:26-29

"Many patients referred to a specialized hospital with chronic
fatigue syndrome have embarked on a struggle. This may take the form
of trying to find an acceptable diagnosis, or indeed any diagnosis
and may involve reading the scientific literature. One of the
principal functions of therapy at this stage is to allow the patient
to call a halt without loss of face. [ME patients are in] a vicious
circle of increasing avoidance, inactivity and fatigue. The patient
should be told that it is now time to 'pick up the pieces' (and) the
process is a transfer of responsibility from the doctor to the
patient, confirming his or her duty to participate in the process of
rehabilitation in collaboration with the doctor. Occasionally
patients may say they cannot take drugs (but) there is no clinical
evidence that allergies exist in anything but a small number of
sufferers, and their existence may be coincidental. Anxiety is often
part of the syndrome (and) sexual problems occur in the majority of
patients referred to hospital. The notion of allergies reinforce the
view that the sufferer is under attack from outside elements which
have nothing to do with himself or herself".


Attribution and self-esteem in depression and Chronic Fatigue
Syndrome. R Powell, R Dolan, S Wessely. J Psychosom Res

"This research shows that in CFS, (patients) experience less guilt:
such an external style of attribution has certain advantages;
external attribution protects the patient from being exposed to the
stigma of being labelled psychiatrically disordered, (affording)
diminished responsibility for one's own health. Our results are
close to those predicted by 'learned helplessness'. Inappropriate
referrals to physicians can lead to extensive physical investigation
that may then perpetuate the symptom pattern of physical attribution"


Chronic fatigue and myalgia syndromes. Wessely S. In:
Psychological Disorders in General Medical Settings. eds: N
Sartorius et al pub: Hogrefe & Huber 1990

"Most CFS patients fulfil diagnostic criteria for psychiatric
disorder. Symptoms include muscle pain and many somatic symptoms,
especially cardiac, gastrointestinal and neurological. Do any of
these symptoms possess diagnostic significance? The answer is
basically negative. It is of interest that the 'germ theory' is
gaining popularity at the expense of a decline in the acceptance of
personal responsibility for illness. Such attribution conveys
certain benefits, in other words, there is avoidance of guilt and
blame. It is this author's belief that the interactions of the
attributional, behavioural and affective factors is responsible for
both the initial presentation to a physician and for the poor


Old wine in new bottles: neurasthenia and ME. Simon Wessely.
Psychological Medicine 1990:20:35-53

"It is assumed that ME is an organic disorder of the peripheral or
central nervous system. In the initial reports this was indicated
by frank neurological signs (but) the concept of ME has
in neurasthenia, the emphasis is on muscle a
current leading neurology text book (Adams and Victor, 1985) chronic
fatigue, neurasthenia and depression are seen as synonymous. Mood
disorder is found in many cases of ME but it is not the only
psychiatric disorder (and) some patients do satisfy the criteria for
anxiety and phobic disorders.Beard's neurasthenia began as a
physical provided the most respectable label for
distressing, but not life-threatening complaints, one that conferred
many of the benefits - and fewest of the liabilities- associated
with was preferable to the alternatives ---
hypochondria, malingering and insanity. There is little evidence of
any change in the current era. Suggestible patients with a tendency
to somatize will continue to be found among sufferers from diseases
with ill-defined symptomatology until doctors learn to deal with
them more effectively. The social processes that govern the
creation of such illnesses remain obscure but one may argue that
they represent culturally sanctioned expressions of distress. It
has been shown that some patients have always preferred to receive,
and well-meaning doctors to give, a physical rather than a
psychological explanation for ill-defined illnesses associated with
fatigue. Such uncritical diagnoses may reinforce maladaptive


Possible ME. Simon Wessely. The Practitioner 8 March 1990:234:195-

"ME is a description, not a diagnosis".


The chronic fatigue syndrome-myalgic encephalomyelitis or postviral
S.Wessely PK Thomas. In: Recent Advances in Clinical Neurology.
ed: Christopher Kennard. pub: Churchill Livingstone 1990 pp85-131

"There is no doubt that at least half of CFS patients have a
disorder of mood. The management of affective disorders is an
essential part of the treatment of CFS/ME. Numerous trials attest
to the efficacy of tricyclic antidepressants in the treatment of
fatigue states. Patients who fail to respond should be treated
along similar lines to those proposed for treatment-resistant
depression, especially (with) lithium".


Editorial. Wessely S. Journal of Neurology, Neurosurgery and
Psychiatry 1991:54:669-671

"Studies of dynamic muscle function have demonstrated essentially
normal muscle strength, endurance and fatigability, other than as a
consequence of physical inactivity. Advice that antidepressants may
be counter-productive is misguided".


Cognitive behaviour therapy in chronic fatigue syndrome. Butler S,
Chalder T, Ron M, Wessely S. JNNP 1991:54:153-158

"Continuing attribution of all symptoms to a persistent 'virus'
preserves self-esteem".


The psychological basis for the treatment of CFS. Wessely S. Pulse
of Medicine 14th December 1991:58

"The prognosis may depend on maladaptive coping strategies and the
attitude of the medical profession".


The epidemiology of fatigue: more questions than answers. Lewis G,
Wessely S. Journal of Epidemiology and Community Health 1992:46:92-97

"We suggest that many patients currently labelled as having 'CFS'
may lie at the extreme end of a continuum that begins with the
common feeling of tiredness. Studies usually find a high prevalence
of psychiatric disorder amongst those with CFS, confirming that
physicians are poor at detecting such disorders".


Chronic fatigue syndrome: current issues. Wessely S. Reviews in
Medical Microbiology

"Validation is needed from the doctor. Once that is granted, the
patient may assume the privileges of the sick role (sympathy, time
off work, benefits etc)"

On 10th January 1992 Wessely wrote a letter to Dr Mansel Aylward at
the Department of Social Security in which he stated

"It is certainly true that I and my colleagues consider that anxiety
about the consequences of activity is one of the factors
perpetuating disability in CFS. I have previously been involved in
advising the DSS that CFS should not be grounds for permanent

Following Wessely's advice, the 1994 Disability Living Allowance
Handbook entry on CFS states "The general consensus of informed
medical opinion is that treatment should be by graded exercise and
rehabilitation (and) antidepressant drugs may be helpful".


The psychology of multiple allergy. LM Howard, S Wessely.

"Many people present to their doctor with multiple unexplained
symptomatology which they attribute to allergy. Those at the
extreme end of this range often attract a diagnosis of total allergy
syndrome, multiple chemical sensitivity, or environmental illness.
A recent study confirmed that psychological symptoms were a central
component of chemical sensitivity. Inherent in the concept of
allergy is the avoidance of any blame. Sufferers from allergies
feel no guilt about their condition and are not subject to moral
sanction. Sufferers from mysterious condition that lie outside
conventional medical practice no longer consider themselves to be
oppressed by spirits and demons but by mystery gases, toxins and
viruses. This is particularly visible in the changing nature of
mass hysteria".


Patients with medically unexplained symptoms. Alcuin Wilkie, Simon
Wessely. British Journal of Hospital Medicine: 1994:51:8:421-427

" Most doctors in hospital practice will be familiar with patients
who complain about a wide variety of symptoms but whose physical
examination and investigations show no abnormality.(Such) symptoms
have no anatomical or physiological basis. Patients at the severe
end of the spectrum exert a disproportionately large and avoidable
financial burden on the health and social services..Patients with
inexplicable physical symptoms are usually strongly resistant to any
psychological interpretation (and) are generally viewed as an
unavoidable, untreatable and unattractive burden".


Population based study of fatigue and social distress. Pawlikowska
T, Chalder T, Wallace P, Wright DJM, Wessely S. BMJ 1994:308:763-

"In recent years, fatigue has attracted renewed attention, largely
because of the prominence given to the chronic fatigue syndrome.
The infective characteristics may be the result of referral patterns
and illness behaviour. The chronic fatigue syndrome may represent a
morbid excess of fatigue rather than a discrete entity. The
definition may have arisen as a result of referral patterns to
specialists. Muscle pain was related to psychological morbidity".


The patient with chronic fatigue. Simon Wessely et al West of
England Medical Journal

"The aims of treatment were to provide alternative explanations for
symptoms. The methods chosen included the use of established
techniques to treat depression, namely, dothiepin".


A cognitive-behavioural approach to chronic fatigue syndrome.
Alicia Deale Simon Wessely The Therapist 1994:2;1:11-14

"Behavioural, attributional and cognitive factors are central to the
perpetuation of fatigue. It is important to note that the rates of
depression and anxiety in CFS are far too high to be explained
solely as reactions to chronic illness".


Psychiatry in the allergy clinic: the nature and management of
patients with non- allergic symptoms. LM Howard, S Wessely.
Clinical and Experimental Allergy 1995:25:503-514.

"Many doctors are frequently consulted by patients with persistent
unexplained symptoms attributed to allergy or chemical sensitivity.when
patients are told there is no evidence of any underlying
immunological or allergic cause, they can be difficult to manage.
In some cases patients claim allergy to almost all of the
environmental products of the Western world. The illness is
usually sporadic but epidemics have been described. Such epidemics
overlap with the related subject of mass psychogenic illness, a term
which has partly replaced mass hysteria. The epidemiology of
environmental illness is reminiscent of the difficulties encountered
in distinguishing between the epidemiology of myalgic
encephalomyelitis (ME), a belief, and chronic fatigue syndrome, an
operationally-defined syndrome. [ Note: The World Health
Organisation does not regard ME as " a belief", but as a
neurological disorder ]. These patient populations recruited from
the environmental subculture are a subgroup of patients who can be
expected to show unusually strong beliefs about the nature of their
symptoms, associated with a high prevalence of psychiatric
disorder. These patients typically resist any attempt to discuss
the possibility of a psychological cause. Somatization sufferers
consume vast amounts of health resources for little benefit.
Between a quarter and a half of new patients attending medical
clinics do not have an organic explanation for their symptoms,
(receiving) a diagnosis of chronic fatigue syndrome. The risk of
psychiatric diagnosis is known to increase linearly with the number
of symptoms with which the patient presents. Attribution of
unexplained symptoms to a "virus", as happens in most patients with
the label of ME, may preserve self-esteem and protect against the
stigma of psychiatric disorder. These total allergy syndromes are
akin to culture-bound syndromes afflicting modern developed
societies where sufferers from unexplained symptoms no longer see
themselves as possessed by devils or spirits but instead by gases,
toxins and viruses. When a psychiatric disorder is not recognised,
patients are often investigated extensively for organic disease;
there are hazards in these inappropriate investigations, as
patients' beliefs in organic pathology are reinforced. Further
investigations will add nothing to the management but will reinforce
the patient's beliefs in organic pathology (and) add to the cost of
the consultation. Patients will benefit from training in cognitive
coping skills; (and some) patients should be treated with
psychotropic drugs. Liaison between the physician and the liaison
psychiatrist is necessary so that patient acceptance of psychiatric
referrals can be facilitated".


Chronic fatigue syndrome: an update. Anthony J Cleare, Simon C
Wessely. Update 1996:14 August:61.

" Chronic fatigue may be better understood by focusing on
perpetuating factors and the way in which they interact in self-
perpetuating vicious circles of fatigue, behaviour, beliefs and
disability. The perpetuating factors include inactivity, illness
beliefs and fear about symptoms, symptom focusing, and emotional
state. CFS is dogged by unhelpful and inaccurate illness beliefs,
reinforced by much ill-informed media coverage; they include fears
and beliefs that CFS is caused by a persistent virus infection or
immune disorder. Increased symptom focusing occurs in CFS
sufferers; (this) increased concern leads to selective attention
and 'body watching': this can intensify the perceived frequency of
symptoms, thereby confirming illness beliefs and reinforcing illness


Chronic fatigue syndrome: a stress disorder? Anthony J Cleare
Simon C Wessely
British Journal of Hospital Medicine: 1996:55:9:571-574

"Between half and two thirds of patients with CFS have a co-morbid
psychiatric disorder".


Chronic fatigue syndrome: a practical guide to assessment and
management. Sharpe M, Chalder T, Wessely S et al General Hospital
Psychiatry 1997:19:3:185-199.

" The majority of patients seen in specialist clinics typically
believe that their symptoms are the result of an organic disease
process, and resent any suggestion that they are psychological in
origin or psychiatric in nature. Many doctors believe the
converse. (Patients') beliefs are probable illness-maintaining
factors and targets for therapeutic intervention. Many patients
receive financial benefits and payment which may be contingent upon
their remaining unwell. Gradual recovery may therefore pose a
threat of financial loss. Abnormal physical signs should not be
accepted as compatible with a diagnosis of CFS. The only treatment
strategies of proven efficacy are cognitive behavioural ones. We
have developed a more intensive (CBT) therapy (which) is acceptable
to patients, safe, and more effective than either standard medical
care or relaxation therapy. It has also been shown to be cost-
effective. An important task of treatment is to return
responsibility to the patient for management and rehabilitation
without inducing a sense of guilt, blame or culpability for his /
her predicament".


Clinics in Controversy: Chronic Fatigue Syndrome.
Anthony J Cleare Simon C Wessely. Update 20 May 1998:1016-1026.

"CFS may be better understood as the extreme end of a spectrum that
starts with 'feeling

tired all the time'. Many people suggest that the condition should
be called ME, but doctors and the editors of journals have taken a
firm stand against this label. The GP's response may be important.
A sick note and unclear diagnosis are both associated with
development of CFS".


Functional somatic syndromes: one or many? S Wessely, C Nimnuan, M
Sharpe. Lancet 1999:354:936-939.

" We postulate that the existence of specific somatic syndromes is
largely an artefact of medical specialisation. That is to say that
the differentiation of specific functional (ie. psychiatric)
syndromes reflects the tendency of specialists to focus on only
those symptoms pertinent to their speciality, rather than any
real differences between patients.Various names have been given to
medically unexplained symptoms. These include somatisation, somatoform
disorders.and functional somatic symptoms.we define a functional
somatic symptom as one that, after appropriate
medical assessment, cannot be explained in terms of a conventionally
defined disease. Functional somatic syndromes pose a major
challenge to medicine. Those symptoms are associated with
unnecessary expenditure of medical resources. Chronic fatigue
syndrome is associated with worse disability than conditions such as
heart failure. three quarters of patients had symptoms more than 10
years after presentation. Thus, functional somatic complaints
constitute a large.and costly health-care issue that urgently
requires improved management. Many of these (functional somatic)
syndromes are dignified by their own formal case definition and body
of research. We question this orthodoxy and ask whether these
syndromes represent specific diagnostic entities (eg. irritable
bowel syndrome, premenstrual syndrome, fibromyalgia,
hyperventilation syndrome, tension headaches, globus hystericus,
multiple chemical sensitivity, chronic fatigue syndrome) or are
rather more like the elephant to the blind man --- simply different
parts of a larger animal?..Such patients may have variants of a
general functional somatic syndrome. If we accept that functional
somatic syndromes are considered together, we open the way for more
general strategies for their management..Functional somatic symptoms
and syndromes are a major health issue. They are common, and
may be costly. Most of the current literature pertains to
specific syndromes. We have put forward the hypothesis
that the acceptance of distinct syndromes as defined in the medical
literature should be challenged. We contend that the patients so
identified.have much in common.We propose an end to the belief that
each different syndrome requires its own particular sub specialist.A
previous generation of physicians noted overlaps
between "psychosomatic syndromes". Unfortunately, none of these
theories were accompanied by empirical support and consequently have
disappeared from our current thinking. We argue that their re-
instatement is overdue".


Responding to Mass Psychogenic Illness. Editorial: Simon Wessely.
The New England Journal of Medicine 2000:342:2:129-130

"Such outbreaks are not novel. In a previous era, spirits and
demons oppressed us. Although they have been replaced by our
contemporary concern about invisible viruses, chemicals and toxins,
the mechanisms of contagious fear remain the same. The
term 'psychogenic illness' and its predecessor 'mass hysteria'
exemplify the problem. To the majority of observers, including most
professionals, these symptoms are indeed all in the mind. It is now
commonplace to blame our environment for many of our ills. Should
we investigate at all? How do you convey the message that the main
mechanisms for the transmission of distress are psychosocial and
behavioural? A firm public message that certain symptoms are
probably psychological in origin will probably help prevent their


Chronic fatigue syndrome: Symptom and Syndrome. Wessely S. Annals of
Internal Medicine 2001:134: 9S:838-843

"Social, behavioural and psychological variables are important in
both chronic fatigue and chronic fatigue syndrome. The lack of
congruence between the patient's report of feeling tired and
exhausted and objective measures of fatigability further frustrate
clinicians and investigators. Compelling evidence of abnormal
neuromuscular fatigability in patients with the chronic fatigue
syndrome is lacking. Fatigue can be related to psychological
variables such as belief and expectation. Some of the desire to
split the chronic fatigue syndrome into subgroups is driven by
emotion. It is interesting to note how some of those who advance
this argument assume that "their" condition (the one they suffer
from, research or treat) will fall on the physical side of the
divide. The greater the number of symptoms and the greater the
perceived disability, the more likely clinicians are to identify
psychological, behavioural or social contributors to illness. The
pressure to reify the chronic fatigue syndrome comes from the way in
which the developed world organizes medical services and
reimbursement systems. Some of the modern impetus to 'allow' a
specific chronic fatigue syndrome arises from the various
compensation and social insurance schemes operating in developed
countries. If the chronic fatigue syndrome did not exist, our
current medical and social care systems might force us to invent
it. Other symptoms identified in the chronic fatigue syndrome
(include) increased symptom-monitoring and increased anxiety".

In correspondence arising from this paper, Wessely wrote "I can
sleep easy at night when it comes to treatment. I know that we have
done more good than harm. You mention the views of Paul Cheney, but
I must say I disagree profoundly with them - and more importantly,
so does every neurologist I have ever met. All I know is that I am
quietly proud of what our group has achieved over the years".


How many functional somatic syndromes? C Nimnuan, S Rabe-Hesketh,
Simon Wessely, Matthew Hotopf. Journal of Psychosomatic Research

"Experiencing symptoms is part of normality. Most of these symptoms
are not associated with clear-cut biomedical diagnosis and are then
referred to as "medically unexplained" or "functional". Functional
somatic symptoms are an important problem in general medicine on
account of the high associated consumption of health service
resources. Such symptoms may be elevated to the status of a
syndrome to which a specific name is attached. These include
irritable bowel syndrome, pre-menstrual pain, fibromyalgia and
chronic fatigue syndrome. Physicians instinctively seek and treat
only conditions they know well. Patients may be seen in several
clinics, which increases the risk of over-investigation. We argue
that such an approach is outdated. Instead, an appreciation of the
fundamental unity of those syndromes may reduce the potential for
iatrogenic harm ".


Modern worries, new technology, and medicine Keith Petrie
Simon Wessely
Editorial: BMJ 2002:324:690-691

" People's suspicion of modernity has increased to such an extent
that it has increased their worries about environmental causes of
poor health and fostered a migration to complementary medicine. We
believe that these concerns have important implications for the way
patients interact with health services. In clinical settings
patients are reluctant to start medication for fear of
putting 'unnatural chemicals' into their body. At the same time the
consumption of unproved herbal and alternative 'natural' remedies is
increasing. This anxiety is reflected in the presentation of
psychosomatic illness: the number of illnesses attributed to
environmental factors --- for example, multiple chemical
sensitivity, total allergy syndrome --- has increased. Normal
everyday symptoms such as headache and fatigue are now more easily
interpreted as signs of disease or ill health. Attributions made by
patients about the cause of their illness often involve
environmental pollution, and they see the effects of modern life as
undermining the effectiveness of their immune system. Distrust of
experts is now commonplace, and at its extreme it can merge into the
conspiratorial thinking that is part of a modern paranoid style.
Mismanaged environmental incidents add to the fear of the public.
New and unsubstantiated health worries can be instantly transmitted
to an internet audience eagerly seeking information on health, or to
special interest networks such as illness support groups. We
believe it is only a matter of time before a mass psychogenic
illness is identified as being spread electronically".


Managing patients with inexplicable health problems. B Fischhoff
Simon Wessely
BMJ 2003:326:595-597

"Those with medical mysteries will find some explanation. When a
medical explanation is slow in coming, physicians, officials and
companies often bear the brunt of (patients') anger, for example in
chronic fatigue syndrome and Gulf war sickness, authorities who
denied sufferers' claims met with scorn and contempt. In this
article we discuss how illness beliefs arise and suggest principles
for dealing with patients. It is only human for doctors to view
the public as foolish, uncomprehending, hysterical or malingering.
One challenge arises when patients have named their condition in a
way that leaves doctors uncomfortable, as occurred with chronic
fatigue syndrome. It may seem that adopting the lay label
reinforces the perceived disability. A compromise strategy
is 'constructive labelling': it would mean treating chronic fatigue
syndrome as a legitimate illness while gradually expanding
understanding of the condition to incorporate the psychological and
social dimensions. The recent adoption by the UK Medical Research
Council and the chief medical officer's report of the term CFS/ME
reflects such a compromise, albeit it an uneasy one".


Medically unexplained symptoms: exacerbating factors in the doctor-
patient encounter.
LA Page, S Wessely Journal of the Royal Society of Medicine

"This paper proposes that well-intentioned actions by medical
practitioners can exacerbate or maintain medically unexplained
symptoms (MUS). This term is now used in preference
to 'somatisation'. The medical specialties employ shorthand
descriptions for particular clusters of MUS, including irritable
bowel syndrome, fibromyalgia and chronic fatigue syndrome. Examples
of precipitating events include muscle ache after unaccustomed
exercise. As one expert notes, 'It is a commonplace clinical
observation that somatising patients --- more than any other group --
-resent psychiatric referral'. Once a patient feels discredited,
the opportunity to explore psychosocial factors is lost. For
patients with MUS, the sensory experiences tend to outweigh the
negative results of a doctor's examination or investigations. Thus
one sees how the cycle of excessive investigation can begin. If
enough investigations are performed, minor and irrelevant
abnormalities will be detected and themselves become hypothesis-
generating. Reassurance is particularly important in patients who
have hypochondriasis or MUS. The adoption of a label such as CFS
affords the sufferer legitimacy --- in other words, it allows entry
into the 'sick role'. The external acknowledgement that the
condition is 'legitimate' is both reassuring and enabling. However,
the conferring of a label is not a neutral act, since specific
labels are associated with specific beliefs and attitudes. In CFS
for example, use of this term or the alternative 'myalgic
encephalomyelitis' implies underlying assumptions about aetiology
and treatment for both patients and doctors. (In relation to
treatment), there is evidence to suggest that harm occurs at the
hands of non-medical practitioners (who) colluded with patients'
abnormal illness beliefs. If sections of the media advocate an
exclusively organic model, as has happened with CFS, the biomedical
model may become firmly enshrined for patients and families at the
expense of psychosocial models. Clearly there are implications for
the way doctors are taught to assess and treat these patients".

Only by assembling and distributing the great wealth of published
medical and scientific evidence which shows unequivocally that
Wessely and his like-minded psychiatrists are wrong is there any
hope of refuting their erroneous assertions and of limiting the
unquantifiable damage that flows from them.

Both the ME Association and Action for ME were set up as charities
to promote and protect the interests of their members, ie. those
suffering from ME (and the term is incorporated into their
charitable status). Neither currently does so, since the Chief
Executives of both charities seem only too happy to subscribe to the
Wessely School view (which ensures continued Government funding).

A Co-cure (internet) posting by Jill McLoughlin expresses the nature
of the problem succinctly:

"It is because our medical community, professional societies and
public health officials have not adequately gathered together,
assimilated, integrated and made public the strong body of research
pointing to the serious physical (not psychological) nature of this

Cont/ jan 21

Posted by peter200015 at 4:24 PM EAST
Updated: Saturday, 7 August 2004 3:00 PM EADT
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