Brian Walitt, the coordinator of the NIH's Clinical Centers chronic fatigue syndrome (ME/CFS) trial co-authored a paper which stated that both ME/CFS and FM are "psychosomatic disorders". The authors characterized psychosomatic disorders as disorders in which patients subjective experience of their cognitive abilities do not reflect the cognitive losses that show up in studies; i.e. the patients were less worse off cognitively than they said they were.
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[/fright]The authors asserted that chronic fatigue syndrome and fibromyalgia are real, biologically based disorders and suggested immunological and epigenetic therapies as treatments but use the "P" word was overwhelming. The word psychosomatic carries connotations of a disease that is "not real" and is "all in one's head". During a recent conference call Walitt asserted that these disorders were biologically based, were not in one's head and were very real indeed.
I took the recent publication of a Walitt to take another look at him, his hypothesis and cognition in FM and ME/CFS.
Psychosomatic is not a term that has been embraced by many in FM or ME/CFS. A PubMed fibromyalgia search found only a few studies, out of thousands, that used the term. Whatever Walitt's biological views of these disorders his own perceptual view of them - that they are also psychosomatic disorders - appears to be held by only a few.
Perceptual Vs Real Cognitive Problems in Fibromyalgia and Chronic Fatigue Syndrome
In the Chemobrain paper Walitt use of cognitive study results to classify FM, ME/CFS, GWS and other diseases as psychosomatic disorders prompted another look at past cognitive studies in ME/CFS and particularly FM. That look suggested that Walitt's conclusion that "These disorders (ME/CFS, FM, GWI, POTS, etc.) are characterized by distressing subjective cognitive impairment without clinically obvious cognitive deficits" would probably not meet agreement with many. In fact, many studies have found obvious cognitive deficits that they apparently consider clinically relevant. Check out some findings below.
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Walitt's use of a paper to back up this observation: "Objective differences noted on cognitive testing also correlate poorly with self-perception of cognitive deficits (Tesio et al., 2015)", suggested that he was scrambling to find supportive evidence. The Tesio paper's main conclusion referred to objective cognitive impairments - not self-perception at all.
In fact when it came to differentiating objective and subjective reports of cognition, the Tesio paper noted "the objective and subjective reports do not capture the same level of definition and, consequently, may not correlate completely."
Walitt seems to be skating on thin ice in other ways. He used a study which determined that FM patients are not too cognitively impaired enough to be able to drive to back up his assertion that FM patients are not, in reality, all that cognitively impaired.
Real World Disconnect?
How does Walitt account for the disparities in his and others assessment of the cognitive issues in FM? One way he is by discounting studies that used stressors such as distraction to uncover the cognitive issues in FM. That's an odd position for the co-author of a Chemobrain paper that proposed using stressors to uncover the physiological basis of these disorders to take.
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[/fright]How ironic it is, as well, that Walitt discounts the results studies which introduce real world elements such as distraction or stress into their studies while arguing that other cognitive tests lack clinical relevance. One might ask why antiseptic laboratory conditions should ever reflect the real world cognitive issues affecting FM and ME/CFS patients particularly given their problems with distraction.
Couldn't problems with distraction account for the differences Walitt claims to see between patients perceptions and their results in laboratory testing? Studies do show that ME/CFS patient's brains have difficulty turning off their attention to innocuous stimuli - innocuous stimuli that probably wouldn't show up in a laboratory environment.
Some Support
Walitt's hypothesis is not without backing. A recent study did find little correlation between subjective and objective measures of cognition in ME/CFS; i.e. it found no objective differences in cognition between ME/CFS patients and healthy controls). (Most ME/CFS cognitive studies have found problems with cognition.)
In a recently published study Walitt did not find significant differences between between the cognitive capabilities or in the kind of brain activation between FM patients and controls.
Neuroimage Clin. 2016; 11: 173–180.Characterizing “fibrofog”: Subjective appraisal, objective performance, and task-related brain activity during a working memory task
Brian Walitt,a,b,⁎ Marta Čeko,a Manish Khatiwada,c John L. Gracely,a Rakib Rayhan,d John W. VanMeter,c and Richard H. Gracelye
He, did, however, find that healthy controls were pretty accurate in how well they perceived they did on the cognitive tests while FM patients were off by about 25% of. Furthermore, the FM patients reduced ability to perceive how accurate they were showed up in the reduced activation of some brain areas. It appeared that areas of the brain (PMC/DLPFC, right anterior insula, and bilateral putamen) the healthy volunteers were using to assess how well they did on cognitive testing simply did not get engaged in the FM patients. That could provide a biological construct for Walitt's ideas.
Conclusions
The question is how important those ideas are. Walitt believes that subjective perception is the key factor in understanding fibrofog (and no doubt other issues) in FM, and that the cognitive issues in the disease are "clinically insignificant".
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[/fleft]Numerous studies, however, have found clear cognitive problems in FM and ME/CFS and biological reasons for them are being uncovered. Reduced cardiac vagus nerve functioning was associated with reduced cognitive functioning in ME/CFS. Medow was able to return cognitive function to normal in ME/CFS patients by using phenylephrine to increase cerebral blood flows.
Cook appears to be finding reduced cognition and altered brain activation after exercise in his Solve ME/CFS Initiative brain study and Lange found altered patterns of brain activation in response to cognitive challenges in ME/CFS.
Meanwhile Walitt is putting a lot on that 25% difference in perceived cognitive functioning. He'll certainly have a chance to review his ideas during the Clinical Center ME/CFS study. The study will do cognitive, blood, autonomic nervous system, microbiome, saliva and other testing before and after exercise.
Walit, it should be emphasized, is simply the coordinator of the study; he will not be doing any testing or writing any papers. He will, however, be closely observing the ME/CFS patients and the results. Time will tell what the results will be. One wonders, though, if his views on the "psychosomatism" found in ME/CFS and FM will change.
[fright]
I took the recent publication of a Walitt to take another look at him, his hypothesis and cognition in FM and ME/CFS.
Psychosomatic is not a term that has been embraced by many in FM or ME/CFS. A PubMed fibromyalgia search found only a few studies, out of thousands, that used the term. Whatever Walitt's biological views of these disorders his own perceptual view of them - that they are also psychosomatic disorders - appears to be held by only a few.
Perceptual Vs Real Cognitive Problems in Fibromyalgia and Chronic Fatigue Syndrome
In the Chemobrain paper Walitt use of cognitive study results to classify FM, ME/CFS, GWS and other diseases as psychosomatic disorders prompted another look at past cognitive studies in ME/CFS and particularly FM. That look suggested that Walitt's conclusion that "These disorders (ME/CFS, FM, GWI, POTS, etc.) are characterized by distressing subjective cognitive impairment without clinically obvious cognitive deficits" would probably not meet agreement with many. In fact, many studies have found obvious cognitive deficits that they apparently consider clinically relevant. Check out some findings below.
Clinical and laboratory evidence confirm that dyscognition is a real and troubling symptom in fibromyalgia (FM), and that the cognitive mechanisms most affected in FM are working memory, episodic memory, and semantic memory. Glass 2009
Patients with fibromyalgia frequently complain of cognitive problems or "fibrofog." The existence of these symptoms has been confirmed by studies of the incidence of cognitive problems in fibromyalgia patients and by the results of objective tests of metamemory, working memory, semantic memory, everyday attention, task switching, and selective attention. The results of these tests show that fibromyalgia patients have impairments in working, episodic, and semantic memory that mimic about 20 years of aging.
Glass 2008
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The studies performed so far have provided increasing evidence that FM patients have attention and working memory deficits, which are most prominent when patients have to cope with an additional source of distraction. Schmidt-Wilke 2010
The patients' test performance was substantially reduced, particularly in terms of lower speed of cognitive processing and restricted improvement of performance in the course of the task. …..The data corroborate the presence of substantial cognitive impairment in FMS. Reyes 2012
The findings validate the perception of failing memory in patients with FM and are the first psychometric based evidence to our knowledge of short-term memory problems in FM linked to interference from a source of distraction. Adding a source of distraction caused the majority of FM patients to retain new information poorly, and may be integral to an understanding of FM memory problems. Leavitt 2006
Walitt's use of a paper to back up this observation: "Objective differences noted on cognitive testing also correlate poorly with self-perception of cognitive deficits (Tesio et al., 2015)", suggested that he was scrambling to find supportive evidence. The Tesio paper's main conclusion referred to objective cognitive impairments - not self-perception at all.
"Our results confirmed the presence of impairments of attention, long-term memory, working memory, and shifting and updating executive functions in FM patients compared with healthy controls." Tesio 2015
In fact when it came to differentiating objective and subjective reports of cognition, the Tesio paper noted "the objective and subjective reports do not capture the same level of definition and, consequently, may not correlate completely."
Walitt seems to be skating on thin ice in other ways. He used a study which determined that FM patients are not too cognitively impaired enough to be able to drive to back up his assertion that FM patients are not, in reality, all that cognitively impaired.
Real World Disconnect?
How does Walitt account for the disparities in his and others assessment of the cognitive issues in FM? One way he is by discounting studies that used stressors such as distraction to uncover the cognitive issues in FM. That's an odd position for the co-author of a Chemobrain paper that proposed using stressors to uncover the physiological basis of these disorders to take.
[fright]
Couldn't problems with distraction account for the differences Walitt claims to see between patients perceptions and their results in laboratory testing? Studies do show that ME/CFS patient's brains have difficulty turning off their attention to innocuous stimuli - innocuous stimuli that probably wouldn't show up in a laboratory environment.
Some Support
Walitt's hypothesis is not without backing. A recent study did find little correlation between subjective and objective measures of cognition in ME/CFS; i.e. it found no objective differences in cognition between ME/CFS patients and healthy controls). (Most ME/CFS cognitive studies have found problems with cognition.)
In a recently published study Walitt did not find significant differences between between the cognitive capabilities or in the kind of brain activation between FM patients and controls.
Neuroimage Clin. 2016; 11: 173–180.Characterizing “fibrofog”: Subjective appraisal, objective performance, and task-related brain activity during a working memory task
Brian Walitt,a,b,⁎ Marta Čeko,a Manish Khatiwada,c John L. Gracely,a Rakib Rayhan,d John W. VanMeter,c and Richard H. Gracelye
He, did, however, find that healthy controls were pretty accurate in how well they perceived they did on the cognitive tests while FM patients were off by about 25% of. Furthermore, the FM patients reduced ability to perceive how accurate they were showed up in the reduced activation of some brain areas. It appeared that areas of the brain (PMC/DLPFC, right anterior insula, and bilateral putamen) the healthy volunteers were using to assess how well they did on cognitive testing simply did not get engaged in the FM patients. That could provide a biological construct for Walitt's ideas.
Conclusions
The question is how important those ideas are. Walitt believes that subjective perception is the key factor in understanding fibrofog (and no doubt other issues) in FM, and that the cognitive issues in the disease are "clinically insignificant".
[fleft]
Cook appears to be finding reduced cognition and altered brain activation after exercise in his Solve ME/CFS Initiative brain study and Lange found altered patterns of brain activation in response to cognitive challenges in ME/CFS.
Meanwhile Walitt is putting a lot on that 25% difference in perceived cognitive functioning. He'll certainly have a chance to review his ideas during the Clinical Center ME/CFS study. The study will do cognitive, blood, autonomic nervous system, microbiome, saliva and other testing before and after exercise.
Walit, it should be emphasized, is simply the coordinator of the study; he will not be doing any testing or writing any papers. He will, however, be closely observing the ME/CFS patients and the results. Time will tell what the results will be. One wonders, though, if his views on the "psychosomatism" found in ME/CFS and FM will change.
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