virology blog

By David Tuller, DrPH

Proponents of the psychosomatic approach to ME and long Covid–as well as the broader range of so-called “functional” disorders and/or “medically unexplained symptoms”–routinely declare that those who disagree with them are engaging in what they dismissively refer to as mind-body “dualism.” The mind and body are not separate entities, they note, and drawing sharp distinctions between organic and psychological causation is an inherently suspect enterprise.

Ok, then. So why do adherents of this approach keep writing papers that seem fraught with confusion about their own “mind-body dualism” construct? Let’s take one recent example in a prestigious venue: an editorial from a group of French authors in the Journal of Psychosomatic Research called “Why the hypothesis of psychological mechanisms in long COVID is worth considering.” This journal is the official voice of the European Association of Psychosomatic Medicine and is affiliated with the International College of Psychosomatic Medicine. Pretty authoritative stuff.

Surprisingly, the journal’s current and past editors acknowledged, in a revealing 2021 article labeled as a “discussion,” that unblinded studies combined with subjective outcomes have particular issues with bias. And yet the journal’s advisory board includes leading lights of the GET/CBT ideological brigades who don’t recognize that this particular study design can render findings meaningless and uninterpretable. These advisory board members include Denmark’s Per Fink, Germany’s Peter Henningsen, the Netherlands’ Judith Rosmalen, and the UK’s Michael Sharpe and Jon Stone.

Moreover, the journal has distinguished itself in publishing egregious examples of over-claiming by leading members of the GET/CBT ideological brigades. For example, in 2021, the journal published Professor Peter White’s long-term follow-up for his self-help graded exercise therapy program, called GETSET. (Professor White, of course, was one of the three lead investigators of the discredited PACE trial.)

In its “Highlights” section, the article failed to note what should have been its main finding: There were no differences in outcomes between the intervention and comparison groups. Instead, Professor White and his co-authors hyped the intervention as successful based on “within-group” comparisons, which should have been of only secondary interest. (The paper was corrected after I alerted the journal about how the authors had distorted the findings.)  

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Is long Covid a functional disorder?

In the recent Journal of Psychosomatic Research editorial, the authors write:

“Although the potential role of psychological mechanisms in long COVID has long been hypothesized, it has been relatively overlooked so far compared to other potential mechanisms…In certain conditions, genuine symptoms may be experienced without any organic impairment.”

So. The authors are positing two completely separate and distinct kinds of mechanisms that can lead to physical symptoms: “psychological mechanisms” and “organic impairment.” Elsewhere in the piece, the authors assert that “psychological mechanisms are real.”

In other words, this article is arguing that psychological mechanisms are directly causing somatic sensations in the absence of any organic impairment. If comparing the different impacts of these two types of mechanisms is not engaging in “mind-body dualism,” what is? I’m not a philosopher and don’t pretend to have read Descartes. It just seems to me that if you posit that both X and Y can cause Z, you’re positing the independent existence of both X and Y. So why do these folks criticize others for this purported misstep when a form of mind-body dualism seems to be at the heart of their own thinking?

The authors appear to think they are transcending mind-body dualism by invoking the construct of  “functional” disorders, which they define as “the presence of debilitating and persistent symptoms that are not fully explained by damage of the organs they point.” Furthermore, they note, “these disorders are common after an acute medical event, particularly in women, and include psychological risk factors, such as anxiety, depression, and dysfunctional beliefs that can lead to deleterious, yet modifiable health behaviors.”

Absence of evidence of organic impairment based on standard tests and current understanding should not be presented as definitive evidence that symptoms “are not fully explained” by organ damage. Perhaps they are not fully explained by organ damage only at the present time; perhaps they will be explained by organ damage in the future. The apparent assumption is that all currently unexplained “persistent symptoms” are forever unexplainable except by invoking “psychological mechanisms.” This leap of logic is unwarranted.

The passage is also breathtaking in its casual misogyny. Women, it seems, are much more likely than men to harbor “dysfunctional beliefs” about their bodies and their experience of sickness, and much more likely to express psychological distress in the form of bodily symptoms. Perhaps the authors don’t realize that female and male bodies are different? Do they understand that women have higher rates of auto-immune diseases? Hm. I guess since we all know women are hysterics and hyper-emotional, why look further for answers?

Reasonable people would generally agree that stress, anxiety, depression and related states can have an impact on health outcomes, in people with and without other underlying conditions and diseases. Reasonable people could also agree with the authors when, citing observational long Covid research, they state that “at least some persistent symptoms in some patients may be influenced by psychological factors.”

But that’s a modest claim–much more modest than what the authors actually seem to believe. That modest claim aside, the entire thrust of the article is that millions of people around the world are just plain wrong to think pathophysiological processes are causing the disabling symptoms that have devastated their former lives. Instead, the authors’ hypothesis is that, like Pavlov’s dogs, these patients are largely misinterpreting the present because of expectations arising from past experience. As the authors write, physical symptoms “may occur when bottom-up input (i.e., information from body sensors) is overweighted by top-down expectation (i.e., information from prior experiences) in shaping perception.”

It’s all well and good to say that symptoms “may occur” in this manner—but of course that means that they also “may not.” This proposed mechanism is no more than a hypothesis—and one that is essentially impossible to prove or disprove. Yet the authors insist this hypothesis should be taken at face value and assumed to be true for the sake of research and treatment. This expectation would seem to require a certain amount of arrogance.

Near the end, the authors write that, “from a psychosomatic medicine perspective,” misunderstanding of and opposition to their position “originate from the fact that, while psychological mechanisms are ultimately biological (i.e. brain-based), they are often contrasted with biological mechanisms in a dualistic approach.”  

Unfortunately, the authors themselves fall into their own trap. If they insist that psychological mechanisms should not be “contrasted with” biological ones, why are they contrasting “psychological mechanisms” and “organic impairment” in asserting that the former can cause symptoms in the absence of the latter? Isn’t this editorial actually promoting “a dualistic approach” while presenting itself as inveighing against it?

Am I missing something here?