The following on-line response was sent to Annals of Internal Medicine, about the "Barsky, AJ and Borus, JF. Functional somatic syndromes. Annals of Internal Medicine, 1999, 130, 11, 910-921", which was originally published on-line at: http://www.acponline.org/journals/annals/01jun99/barsky.htm

This is the original unedited response. The edited version was published on 15th February 2000 and may be viewed alongside other letters of response at:
http://www.acponline.org/journals/annals/15feb00/functional.htm

It had to be a brief response given the restriction imposed of a maximum of 300 words of text and five references.

To the editor,

Having studied chronic fatigue syndrome (CFS) for over 15 years, I am baffled that Barsky and Borus chose to include it in their review of functional somatic syndromes¹.

CFS is not a single entity. The existing criteria for CFS select a variety of conditions including post-viral fatigue, undiagnosed sleep disorders, ‘burn-out’, atypical depression and symptoms due to hormonal and nutritional deficiencies^{2 3 4}. Given the heterogeneity of the population, there is no reason why there should be a single cause, let alone an identical set of beliefs and behaviours among patients.

The authors’ discussion of CFS was highly selective and clearly aimed at supporting the authors’ hypothesis. When I searched the Medline database, I found little evidence for the alleged link between CFS and incorrect attributions, symptom amplification and the other psycho-social factors mentioned in the article⁵. In fact, many of the arguments seemed to rely on generalisations, over-simplification, and a theory-led blindness to individual differences.

Given the reputation of the journal, I was surprised that this article was published in this form. For instance, the authors were allowed to present opinions as facts, to refer to other reviews rather than the research, and to ignore the many studies which undermined their hypothesis. Would such obvious bias be acceptable in obstetrics or oncology?

If this article was subjected to peer review, it wasn’t very rigorous: Those involved were either not familiar with the subject or they shared the authors’ prejudices. Whatever the reason, their lack of objectivity resulted in the publication of a poorly researched article which misrepresented the research and perpetuated myths. What happened to evidence-based medicine?

Yours faithfully,

Ellen Goudsmit PhD C.Psychol.

1. Barsky AJ and Borus JF. Functional somatic syndromes. Ann Intern Med. 1999, 130, 910-921.

2. Hock AD. Fatigue and 25-hydroxyvitamin D levels. J Chronic Fatigue Syndrome 1997; 3: 117-127.

3. Manu P, Lane TJ, Matthews DA, Castriotta RJ, Watson RK and Abeles M. Alpha-delta sleep in patients with a chief complaint of chronic fatigue. Southern Med J. 1994; 87: 465-470.

4. Lerner AM, Zervos M, Dworkin HJ, Chang C, Fitzgerald JT, Goldstein J et al. New cardiomyopathy: pilot study of intravenous ganciclovir in a subset of the chronic fatigue syndrome. Inf Dis Clin Pract. 1997; 6:110-117.

5. Jason LA, Richman JA, Friedberg F, Wagner L, Taylor R. and Jordan KM. Politics, science, and the emergence of a new disease. The case of chronic fatigue syndrome. Am Psychol. 1997; 52: 973-983