RACP Guidelines for CFS

Response to the CFS Guidelines Revised Draft 2001
Eleanor Stein MD FRCP(C)

July 3, 2001

As a Canadian trained psychiatrist who has had an interest in CFS for many years, who works at a specialist clinic for the treatment of CFS and Fibromyalgia and who has lived and worked in Australia from 1998 - 2001 I have several comments about the most recent draft guidelines of which a few are mentioned below.

First I would like to commend the authors in being more direct about the inappropriateness of viewing CFS as a primarily psychological disorder and of using psychoanalytic concepts such as secondary gain as explanation for presentations. If this is read by primary care physicians there will be much less iatrogenic trauma to CFS sufferers from the medical profession in Australia. Also positive in my view are the acknowledgements that: 1. the disability of CFS sufferers can be considerable and 2. some persons with the disorder can be essentially house or bed bound. These statements will help legitimize the suffering of many.

However the document will fail in its attempt to dissuade physicians from focusing on psychological hypotheses because it does not suggest a plausible alternative. In the absence of evidence of alternatives many readers will fall back on incorrect but familiar psychological assumptions. The failure to mention any of the evidence of physiological and neuropsychological deficits in CFS is disappointing in a document sponsored by an authoritative body who would presumably wish to present an accurate and unbiased view of current medical knowledge.

The authors could hardly be unaware of the repeated findings by unaffiliated groups of autonomic dysfunction, immune dysfunction and neuropsychological dysfunction in CFS {386,672}. A physical examination of CFS patients which does not include testing: for the 18 FM tender points, enlarged, tender cervical/axillary lymph nodes, signs of protein malnutrition such as tongue fissures, Rhomberg's sign and autonomic dysfunction with prolonged standing will in fact ensure that busy GPs will continue to view the physical condition of persons with CFS as 'normal' and will perpetuate the polarized and incorrect views held by many primary care physicians.

Furthermore, the emphasis on mobilization as a primary rehabilitation strategy needs to be presented with caution. It may be harmful to patients (in our practice by far the majority) who are already functioning at beyond their capacity and whose symptoms are worsening as a result. Many of these patients need to manage their activity ie. match energy expenditure to energy supply and need to treat concomitant symptoms such as orthostatic tachycardia before mobilization is possible.

In conclusion, although this document is an advance over the previous version, it will ensure that most persons with CFS in Australia will continue to be inadequately treated compared to persons with CFS in the rest of the developed world. This in a country with the expertise and resources of Australia is a great pity.


Eleanor Stein MD FRCP(C)

Burke clinic for the treatment of chronic pain and fatigue disorders
2210 - 2nd St. SW
Calgary, Alberta T2S 3C3


Alison Hunter Memorial Foundation
PO Box 6132 North Sydney 2059 Australia
Phone/Fax +61 2 9958 6285

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