MAGICAL MEDICINE: HOW TO MAKE AN ILLNESS ... - Invest in ME

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They explain that historically, the classical “CBT model” of emotional distress as proposed by Beck
distinguished between predispositions and precipitants, and perpetuating cognitive, behavioural, affective
and physiological factors, and that the “CBT model retains this general structure and its ‘three Ps’: predisposing,
precipitating and perpetuating factors”.
Deary et al say: “Treatment tends to initially focus on the perpetuating cycle, attempting to dismantle the self‐
maintaining interlock of cognitive, behavioural and physiological responses hypothesised to perpetuate the symptoms”.
According to Deary et al, the “sine qua non of any CBT model is a vicious circle, the hypothesis that a self‐
perpetuating interaction between different domains maintains symptoms” and they postulate that “the CBT models
of MUS, IBS and CFS propose a model of perpetuation that is autopoietic”. Quoting Valera (2005), Deary et al
define autopoiesis as: “the process whereby an organization produces itself…an autonomous and self‐maintaining
unity”. If Deary et al were meaning to refer to the “Father” of autopoiesis, and the person who introduced
the concept of autopoiesis to biology, then that person is Francisco Varela (not Valera), and Varela died in
2001, so it is not clear why Deary et al cite a website and not a peer‐reviewed paper for their autopoiesis
reference. Furthermore, their citation for “Valera (2005)” does not appear on the website in question
(http://pespmc1.vub.ac.be/ASC/AUTOPOIESIS.html ).
Deary et al then say that “The CBT model of perpetuation differs from a more generic biopsychosocial model by
proposing a unique autopoietic interaction of cognitive, behavioural and physiological factors for each
individual….symptoms are (assumed to be) generated not by one disease process but by the interaction of (cognitive,
behavioural and physiological) factors”. Deary et al say they considered as examples of the “CBT model” of
MUS “all models which propose such a process” (notably, not a few of the considered papers were Wessely
School self‐references).
The authors say that although there are varying degrees of evidence for each of the components of their
model, “what is lacking is solid proof of their interaction in vicious circles, although all of the models reviewed
(including their own) assume this interaction”.
Despite their own “assumption”, claiming “coherence” of their “CBT model”, Deary et al say: “the key feature
of CBT model is that these individual components become locked into an autopoietic cycle” and they hypothesise that
in “vulnerable individuals, such as those who are over‐active, CFS is precipitated by life events or viruses leading
to an autopoietic cycle in which physiological changes, illness beliefs, reduced activity, sleep disturbance, distress,
medical uncertainty and lack of guidance interact to maintain symptoms. The evidence supports some of the individual
dots in this picture but not yet the lines between them”.
Their construct of causation clearly includes factors that are mutually exclusive (overactivity as well as
underactivity), which begs the question that their model is all‐embracing and was designed to ensure it can
never be disproven.
Deary et al then state that: “what makes the CBT model so difficult to test may also be one of its chief strengths: it is
in many ways a meta‐model to join the dots of whatever factors each patient presents. Indeed, factors that are neither
strictly cognitive nor behavioural but have been found to be important (for instance, social support [citing Chalder
1998] or benefit receipt can be incorporated into this structure as perpetuating factors”.
Two points arise:
(i) the authors do not consider that many people whose lives are wrecked by ME/CFS are not claiming either
state benefits or permanent health insurance, so how do they fit into their “CBT model”, given that two of
the allegedly perpetuating factors do not apply to them?
(ii) the authors concede that they cannot join the dots to produce the full picture, yet they still hang their
beliefs about their model on individual dots, claiming that some of the dots ‐‐ especially social support and