Dr. Alan Gurwitt's letter to DSM-V Committee of the APA

The Board of Directors of the Massachusetts Chronic Fatigue and Immune Dysfunction
Syndrome/Myalgic Encephalopathy and Fibromyalgia Association (Mass. CFIDS/ME &FM) has
reviewed your proposed revisions of DSM-IV destined for DSM-V. Our particular focus has beenon your newly proposed category "Complex Somatic Symptom Disorder". Our concern is not somuch about the fact that you wanted to simplify terms for somatoform disorders but about thecriteria cited and the potential misuse of the category.
We share the concern, heard from individuals and organizations around the world, that this new
category might be too readily used to include chronic fatigue syndrome ("CFS", also now known
as ME or myalgic encephalopathy) and fibromyalgia as if they are forms of a psychologicaldisorder. Most simply, they are not now psychologically caused illnesses nor have they everbeen so. This concern doesn't come out of the blue. It is based on two and a half decades of
mistaken and harmful misdiagnoses based on totally inappropriate and harmful misconceptionsof what CFS and fibromyalgia are and what they are caused by.

Our organization, celebrating our 25th year of existence helping patients with these illnesses,
has seen firsthand the terrible toll exacted by the trail of misdiagnoses. Patients are tainted,
dismissed, not properly treated, and often referred to equally misinformed mental healthclinicians.

In our view, the key problem is not so much the diagnostic nomenclature as it is the very wrong
conceptions on the part of psychiatrists and non-psychiatric physicians of the very nature andlikely causes of both CFS/ME and FM. There may be psychological disturbances following theonset; these are important but they are secondary.

Over the past fifteen years, increasing numbers of researchers from around the world have
pinpointed the likely biological causes, the complex pathophysiology that follow from the initialinfectious or toxic triggers, and the interacting and dysfunctional multiple body systems(immune, central and peripheral nervous systems, endocrine, cellular [mitochondrial], etc)
involved. Genetic and genomic factors are being elucidated. Certain viruses have long beenimplicated. Most recently a retrovirus, XMRV, has been implicated and is actively being studiedin several centers. While no widely accepted biomarkers are currently available, many key
researchers believe that it will not be long before one or more biomarkers will be found. While
there is no definitive cure as yet, forms of treatment have been developed over the years that
can alleviate many of the symptoms. Here is where mental health clinicians can help; if there
are serious secondary psychological symptoms, certain therapies can help.

Dr. Anthony Komaroff, Professor of Medicine at Harvard Medical School and a long-time

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Dr. Alan Gurwitt's letter to DSM-V Committee of the APA

researcher in the field has said the following:"...there are now over 4,000 published studies that show underlying biomedical abnormalities inpatients with this illness. It's not an illness that people can simply imagine that they have and it‘s not a psychological illness. In my view, that debate, which has waged for twenty years, should
now be over". Four years later there is even more evidence for Dr. Komaroff's assertion.

The bottom line is that CFS and fibromyalgia are not psychological illnesses. It is then essentialthat the American Psychiatric Association vigorously help educate graduate and resident
psychiatrists on this essential truth. While the wording and criteria for "Complex Somatic
Symptom Disorder" will matter so as to avoid confusing chronic fatigue syndrome andfibromyalgia with a somatoform disorder it will be new understanding of the biological nature,proper diagnostic techniques, and appropriate treatments of these illnesses that will matter
most.

Alan Gurwitt, M.D.

President, Massachusetts CFIDS/ME & FM Association(Retired adult and child psychiatrist, Distinguished Fellow of the American Psychiatric
Association)
4/15/10

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