A review by John Sayer
March 2005
"The Psychopathology of Functional Somatic Syndromes: Neurobiology and Illness Behavior in Chronic Fatigue Syndrome, Fibromyalgia, Gulf War Illness, Irritable Bowel, and Premenstrual Dysphoria" - Peter Manu, MD (Haworth Medical Press, 2004)
I didn't have to even finish reading the Introduction before realising what an unscientific, inadequate, poor excuse for a "textbook" this promised to be.
In fact, Haworth themselves admit as much in their Publisher's Note:
"We do not claim that this information is necessarily accurate by the rigid scientific and regulatory standards applied for medical treatment."
That pretty well says it all: in other words this book is, from the point of view of accuracy and scientific and regulatory standards applied for medical treatment - worthless.
At one time, of course, this would have been the very reason for a book such as this to have been rejected for publication.
So why would anyone want to publish it in the first place? Where is the market? Who is the target audience?
I think I can guess. One of Manu's very first references is... something else by himself. This is the first pointer to what is a major exercise in biased referencing. In other words, Manu has drawn upon those sources which are supportive of his theory.
It involves the old technique of a number of writers continually cross-referring one another's work, to give the appearance of there being a wide-ranging body of shared opinion on their particular subject: a mutual admiration society.
And the point? Well, everyone needs source material (and it's tempting to believe that the lengthier one's bibliography, the more learned and academic one's own work appears), so the psychologisers flood the "references" market with their confused and confusing "theories".
In fact, I've been struck by the number of times lately I've read a "research" study which has turned out to be, not actually conducted in real life by the author(s), but merely a paper analysis of information gleaned by a "search", which these days is more than likely conducted, not in libraries and archives, but on the internet.
The opportunities this affords for bias - i.e. bad research - are legion. And that's not even considering the 'hacking' possibilities.
In the electronic world of the "key word", the search engine is the key to the vault of mutually-supportive source material. How many "hits" does one get by typing in "chronic fatigue"? How many compared to, say, "myalgic encephalomyelitis"? (And wouldn't it "hide" the M.E. material even further by using a corruption like "myalgic encephalopathy"?)
I think books like this one serve no better purpose than to corrupt the quality of the source material available to researchers, journalists, health workers, politicians and patients alike. (As I understand it, the only material on M.E. available in the Houses of Parliament libraries is that of a psychiatric flavour; this is certainly a charge justifiably levelled at the BMJ.)
In their Publisher's Note (a complete disclaimer: e.g. "the author, editor and publisher do not accept responsibility in the event of negative consequences incurred as a result of the information presented in this book") Haworth actually claim that "The author has exhaustively researched all available sources to ensure the accuracy and completeness of the information contained in this book."
It is not possible for any human being to have exhaustively researched all available sources. More appear every day.
This claim is pompous and grandiose, as is the tone of the book.
The Introduction begins:
"Chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, premenstrual syndrome, and Gulf War illness are common illnesses that lack demonstrable structural or biochemical abnormalities and are characterized by medically unexplained symptoms such as fatigue, myalgias, abdominal pain, difficulty with concentration, mood lability, and sleep disturbance (Manu,1998)."
Apart from the obvious and glaring fallacy of the claim that these illnesses "lack demonstrable structural or biochemical abnormalities", a devious trick is at play here: what appears to be an authoratitive statement of fact is actually only a paraphrase of the source given in brackets. But it doesn't read that way at first glance, as it follows one of the first rules of journalism, a good example of which being "The Queen Mother is made of green cheese and drinks horse blood, says mental patient."
The very opening paragraph is founded on earlier work by the author himself. This is objective research? Oh, but I forget the Publisher's Note: "We do not claim that this information is necessarily accurate by the rigid scientific and regulatory standards applied for medical treatment."
Of course.
The Introduction continues:
"The way in which these entities have been explained has varied, and some clinicians have interpreted and managed them as physical disorders. However, most physicians have understood them to be mental illnesses (Sharpe and Carson,2001)."
"Most physicians"? Has Dr. Manu conducted a survey, then? Well, this actually comes from, apparently, "Sharp and Carson, 2001" - "'Unexplained' somatic symptoms, functional syndromes, and somatization: Do we need a paradigm shift?" Annals of Internal Medicine 134(9 Part 2):926-930. I haven't read this reference, so I don't know what it actaully says. Nevertheless, it protects Dr. Manu from the accusation that he is wrong; he can claim that he was only quoting a source.
He continues his Introduction by referring to "a recent survey of 400 physicians in the South Thames area of England (Reid et al, 2001). More than half of the respondents (63 per cent) thought that the symptoms were best explained by a psychiatric disorder. An even greater proportion of this physician sample (83 per cent) believed that patients with medically unexplained symptoms have a personality disorder. Most of the respondents (93 per cent) felt that patients with such symptoms are difficult to manage. A solid majority (75 per cent) of these physicians rejected the possibility that the symptoms represented evidence of an undiagnosed physical illness."
Hard statistics! But what are they about? Actually, nothing more than the opinions of 400 physicians. Clearly these physicians think that chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, premenstrual syndrome, and Gulf War illness are all forms of psychiatric/personality disorders. Is this because they are psychiatrists? The answer is, ironically, no, since the Introduction continues:
"These beliefs were not related to the physicians' training in psychiatry or to the availability of mental health resources in the area they served."
So they were not only not psychiatrically trained - thus rendering their opinions of no more value than, say, 400 bus drivers - but also had no access to mental health services (just like bus drivers).
Manu's next reference is to: Reid S, Whooley D, Crayford T, Hotopf M. (2001)."Medically unexplained symptoms - GP's attitude towards their cause and management". Family Practice 18(5):519-523.
Again, a smooth side-step. The key word here is "attitude"; not concern with GPs' research into cause and management of illness, but merely attitude towards it.
Anyway, there doesn't seem much point in even reading the whole book, since "The publisher and author assume no responsibility for errors, inaccuracies, omissions or any inconsistency herein." (Publisher's Note)
To my mind, this is a gross abrogation of responsibility - but that's another story. The sort of thing the publishers probably had in mind is this choice quote (third-hand, via Reid et al) from one of the physicians in the "South Thames area of England" surveyed for their opinions of patients with "symptoms such as fatigue, myalgias, abdominal pain, difficulty with concentration, mood lability, and sleep disturbance":
"'...most of medically unexplained symptoms are related to not wanting to go back to work, and sick benefits usually help to keep away symptoms.'"
Here we have a circular argument of dismissing "medically unexplained" symptoms as being, somehow "related to not wanting to go back to work". Manu doesn't bother to explain the correlation, but then again, he doesn't need to, since he's only quoting someone else's work, which in turn quotes someone else. And we mustn't forget the publisher's claim that Manu "has exhaustively researched all available sources to ensure the accuracy and completeness of the information contained in this book." Sure.
It is no surprise, really, that Manu doesn't appear to notice the gross contradiction (let alone consider the empirical evidence to the contrary) contained in the claim that "'sick benefits usually help to keep away symptoms'": as anyone knows, reliance on benefits (let alone the struggle to obtain them) has exactly the opposite effect, exacerbating and amplifying symptoms.
Analysis and logic, let alone plain common sense, however, don't appear to be Manu's strong points here.
But then again, anyone doing a "search" on the internet, having downloaded this, will probably not need to go beyond the Introduction anyway to get the whole point of the book, and can merrily then write in a newspaper column, weekend colour supplement or official report that
"chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, premenstrual syndrome, and Gulf War illness are common illnesses that lack demonstrable structural or biochemical abnormalities... most physicians have understood them to be mental illnesses" - Dr. Peter Manu, 2004."
And therein lies the tragedy.
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