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Physical or mental? A perspective on Chronic Fatigue Syndrome

Tuesday 24 July 2012


From Advances in Psychiatric Treatment:


RelativityPhysical or mental? A perspective on chronic fatigue syndrome

Richard Sykes

Author affiliations:
Richard Sykes is the Director of Westcare UK (155 Whiteladies Road, Clifton, Bristol BS8 2RF, UK), a registered charity for people with chronic fatigue syndrome/myalgic encephalomyelitis. After taking a degree in Classics at Cambridge University and a PhD in Philosophy at Princeton University, USA, his earlier career was in university teaching and research in philosophy. Career changes led to social and community work and the establishment of Westcare UK in 1989.

This paper examines the question of whether chronic fatigue syndrome (CFS), often known as myalgic encephalomyelitis (ME), should be classified as a physical or mental illness.

The distinction made between physical and mental illness has far-reaching effects. Within medicine there are lists of illnesses considered to be mental disorders which are distinguished from those known as physical disorders. These lists appear in official classifications such as the ICD and the DSM. They are reflected in textbooks which only deal with illnesses considered to be mental ones. Although there is much dispute over some illnesses, there is also a large measure of agreement within medicine about which are to be called mental illnesses and which are not.

This demarcation is reflected in many other ways within medicine. There is a medical speciality which deals with mental illnesses (psychiatry), there is a branch of the National Health Service which deals with mental illnesses (the Mental Health Services), there are specially trained personnel (such as psychiatrists) who deal with people who have mental illnesses and there are special medications (e.g. antidepressants) and other treatments which are considered appropriate for those with mental illnesses.

In the wider world, the distinction between mental and physical illness is also widely used, with similar far-reaching effects. Regrettably, many of these are negative for people whose illnesses are classed as mental. In employment, those with a mental illness label may find themselves at a disadvantage; in financial matters, penalties may be imposed by insurance companies, pensions agencies or the state Benefits Agency; in society generally, there may be stigma.

A financial penalty

A clear example of the financial penalty attached to a diagnosis of mental illness comes from the current regulations relating to the mobility component of the disability living allowance.

The mobility component is paid at two rates. One of the qualifying conditions for the higher rate is that the person must be ‘suffering from physical disablement’. If the disablement is judged to be psychological in origin, rather than physical, the person will only be entitled to the lower allowance. There is a substantial difference between the two rates, currently amounting to £24 per week (£1488 per year). The quality of life of people on a very low income, as those with chronic illnesses frequently are, can be substantially affected through being barred from receiving the higher allowance.

Criticisms of the distinction

Despite its widespread use, the distinction between mental and physical illness is currently the subject of much criticism (Box 1; Kendell, 2001). This can largely be summarised under five headings.

1. Criticisms of the term ‘mental’

A frequent criticism is that this suggests an independently existing (Cartesian) mind (White, 1990; Ware, 1993). As DSM–IV puts it:

‘The term mental disorder unfortunately implies a distinction between ‘mental’ disorders and ‘physical’ disorders that is a reductionistic anachronism of mind/ body dualism’ (American Psychiatric Association, 1994: p. xxi).

2. Misconceptions associated with mental illness

Mental and physical illness are polar opposites. Mental illnesses have only mental symptoms and only mental causes, and only mental treatments are appropriate; physical illnesses have only physical symptoms and only physical causes, and only physical treatments are appropriate.

Mental illnesses are not real, or are less important than physical illnesses.

Individuals with a mental illness are responsible for their condition; they could, if they made an effort of will, pull themselves out of it.

3. The association of stigma with mental illness

Critics argue that if the distinction between mental and physical illness were abolished, or the difference between the two were minimised, this would abolish or reduce the stigma attached to mental illness.

4. Boundary problems in connection with particular illnesses

It is pointed out that the distinction between neurological illnesses and some mental illnesses appears to be arbitrary and is essentially due to historical accident. There are also difficulties in drawing the boundaries of somatoform and similar disorders.

5. Lack of features distinguishing mental from physical illness

The absence of any features of mental illness by which it can be clearly distinguished from physical illness also leads to the lack of any satisfactory definition of the former. Both mental and physical illnesses have mental and physical symptoms, mental and physical causes and can be treated appropriately by mental or physical treatments.

Further responses needed

Such criticisms are important and valuable. However, I suggest (Box 2) that four further responses are needed.

First, care should be taken not to overstate the difficulties associated with the current distinction. Sometimes it is said that the distinction implies Cartesian dualism, but this overstates the problem. The distinction does not imply Cartesian dualism, although it may suggest it to some people. Talking of mental illness does not imply the existence of some independent entity, the mind, any more than to talk about psychological illness implies the existence of some independent entity, the psychology of the person involved. In a similar way we can talk about the side view or the frontal view of a mountain or a person, without implying that the side view and the frontal view exist independently. The fact that two things can be conceptually distinguished (conceptual dualism) does not imply that they have some kind of separate independent existence (ontological or Cartesian dualism).

Second, the distinction between mental and physical illness is sometimes said to be meaningless. This view has been attributed to the authors of DSM–IV (Kendell, 2001). However, to say that a patient has a mental illness is certainly not meaningless. There is a difference between the definition and the meaning of the term. Just because we cannot precisely define mental illness, it does not follow that the term has no meaning. There are lists of illnesses which are considered to be mental illnesses (see ICD–10 and DSM–IV); to say that a patient has a mental illness at least involves saying that he or she has one of the listed disorders or something very similar. Further, as has already been pointed out, to classify an illness as mental rather than physical, can have far-reaching effects for the patient both in the medical treatment provided and in society generally. When patients claim that their illness is a physical one, their claims cannot be brushed off on the grounds that they are meaningless.

Third, the need for some kind of distinction should be recognised. Some kinds of mental illness are very different from some kinds of physical illness and we need a way of marking the difference. Schizophrenia and gout, for example, are very different.

Fourth, there needs to be greater recognition of the importance of finding and introducing a better distinction and taking appropriate action. The current distinction causes difficulties which present a significant impediment to good communication among doctors and between doctors and patients, with unhappy results for both parties. Significant resources need to be devoted to improving the way in which the distinction is drawn, for this apparently theoretical task has important practical implications.

Very importantly, while the distinction is in widespread use, clinicians, including psychiatrists, need to be willing to work with it and use it intelligently in the best interests of their patients.

Why clinicians need to work with the distinction

The reason why clinicians, including psychiatrists, need to work with the distinction is simple, although its importance is often overlooked. If clinicians do not place their patient’s illness in one category or the other, they can be sure that other colleagues will do so. Within medicine, the patient’s illness will be categorised by medical researchers, administrators and nosologists. Outside medicine, administrators in employment and financial agencies will do the same. However, the decision made by others may not be appropriate or fair, or in the best interests of the patient. Many of the financial agencies have vested interests and their decision may reflect those interests rather than the true state of affairs.


The full article can be found here.



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