Scientific Overview
Stress and Stress Tolerance
HPA Axis
Circadian Rhythms
Immune System
Placebo Effect
Chronic Fatigue Syndrome
Chronic Pain
Psychiatric vs Organic Debate
Irritable Bowel Syndrome
Chronic Lyme Disease
Recovery from ME/CFS

Psychosomatic Illness and the Psychiatric vs Organic Debate for Chronic Fatigue Syndrome (CFS)

There is a long-running debate over whether CFS is a psychiatric/psychological illness, or whether it is organic/physical and caused by some external pathogen or disease mechanism. In the UK the medical profession tends to categorise CFS as psychiatric, whereas in most other countries it is classed as an organic illness. Patients themselves tend to be hostile towards psychological explanations for the illness, probably because most of the proponents of psychological theories have very simplistic explanations along the lines of neurosis or feigned illness. There are also a large number of misconceptions about psychosomatic illness, with many people (including doctors) incorrectly believing that psychosomatic illness is imaginary.

Part of the problem is the confusing array of symptoms present in the illness. There are certainly many psychiatric symptoms, such as depression and anxiety, which are present in between 50 and 90% of patients. This in itself does not necessarily point towards a psychiatric mechanism for the illness - these symptoms could simply be a reaction to the illness itself. There are many physiological and physical symptoms, such as abnormal HPA axis activation, autonomic dysfunction, and low blood volume.

CFS is a complex illness which appears to be caused by a breakdown in the systems which are at the boundary of the mind and body — the HPA axis in particular. As such it is wrong to pigeon-hole the illness as either psychiatric or physical, as it does not fit into either category in the traditional sense. Both the triggers for the illness and the symptoms themselves are a combination of psychological and physical/physiological.

Psychosomatic illness

There is a lot of misunderstanding over the term "psychosomatic", even among many doctors and researchers. The term psychosomatic means "physical symptoms caused by psychological factors". Many people incorrectly believe that psychosomatic symptoms are imaginary, or that patients with psychosomatic symptoms are "nuts". The term for imaginary symptoms is "hypochondria", and it refers to a person who worries about having a serious disease in the absence of an actual medical condition. The term for someone who feigns illness is Munchausen syndrome. Psychosomatic symptoms, in contrast, are real physical symptoms which are caused by psychological factors such as stress, worry and emotional upset.

The reality is that everyone experiences psychosomatic symptoms virtually every day. Some common examples include:

Most of these symptoms are temporary and mild, occurring in response to day-to-day stressors. The problem occurs when there is chronic stress — and unresolved stressful emotional issues in particular — which is when the symptoms of burnout, chronic pain and CFS can occur. In these cases the symptoms tend to wax and wane over a longer period of time (similar to major depression), rather than in response to day-to-day stressors, making it less obvious that the symptoms are related to life events.

Some people are skeptical about the reality of psychosomatic illness. However, a cursory look at the science of how the body works shows that not only are chronic psychosomatic symptoms a natural consequence of the body's "design", but it would in fact be impossible for their not to be psychosomatic symptoms. For example: cortisol, the main stress hormone, is also the main immune modulator in the body, so any type of stressor will also influence the immune system. Studies show that students taking examinations have significantly increased Epstein-Barr virus antibody levels in their body, indicating viral reactivation.

Neuroinflammation in depression

Recent research in neuroscience is showing that depression is associated with neuroinflammation, and that psychological stress results in an overactivation of microglia (nervous system immune cells) in the brain. This is similar to the neuroinflammation seen in neurodegenerative disorders such as Alzheimer's, Parkinson's and multiple sclerosis, although the cause is purely psychological in origin.

The brain generally does not differente between physical and psycholgical threats in the same way we do, and sometimes the brain has the same response to both physical and psychological threats (in terms of HPA axis activation, immune activation/suppression, and neuroinflammation).

Chronic pain vs chronic fatigue vs depression

While it is true that chronic fatigue syndrome is not the same as depression, there are certainly many overlaps between chronic pain, chronic fatigue and depression, with many patients experiencing all three.

Pain, fatigue and depression can be thought of as protection mechanisms against injury (in the case of pain), excess energy expenditure (in the case of fatigue), and excess emotional or mental energy expenditure (in the case of depression). While pain and fatigue can be the result of actual physical tissue damage or actual energy expenditure, in many cases there are no physical anomolies causing the pain, and pain is more of a protective mechanism rather than a measure of tissue damage. Similarly, fatigue is not always a measure of actual energy expenditure, and psychological factors have a large influence on fatigue.

Psychosomatic fatigue in athletes

Athletes experience fatigue resulting from the central governor in the brain during every race. The central governor integrates multiple physical and psychological factors in order to generate the sensation of fatigue (which itself is an emotion). Unlike other emotions, the fatigue sensation generated after exhaustion from maximal exercise is very difficult to overcome, due to the fact that the central governor has outputs to the motor cortex. Thus it is fair to say that every athlete experiences severe (albeit temporary) psychosomatic fatigue during every race. In some cases, however, the fatigue can persist, as in the case of overtraining, which appears to be a version of CFS triggered by excessive exercise over a long period of time, with insufficient recovery periods.

Psychosomatic and hypnotic paralysis

Paralysis can be induced in susceptible people using hypnosis, and brain-imaging research has shown that there is a specific brain signature associated with hypnotic paralysis which is different from feigning paralysis. The findings suggest that hypnotic paralysis works by controlling movement through increasing self-imagery and reducing coupling between the areas of the brain which plan movement and the areas which execute it.

Brain studies of patients suffering from functional/psychosomatic paralysis show a similar pattern of brain activation to the hypnotized subjects, suggesting that the same mechanism is involved in both.

Pain can also be suppressed through hypnosis, and hypnosis has been shown to be effective in reducing fibromyalgia pain.

Is CFS psychosomatic?

Certainly psychosomatic factors do appear to be important in perpetuating CFS. Although physical factors such as infections are important in triggering the illness, it appears that psychological factors may be more important in its persistence.

A better term might be "functional", as that implies a disruption in the function of the body, without implying any particular etiology.

A good example of a functional symptom is a so-called tension headache. (So-called because tension headaches are not thought to be caused by muscle tension any more). A number of physical and psychological factors can cause tension headaches such as psychological stress and caffeine withdrawal. The same disruption in the function of the brain can be triggered by both physical and psychological/psychosomatic causes. In both cases the underlying etiology is likely to be similar.


Wikipedia entry on Psychosomatic Illness

Wikipedia entry on Psychoneuroimmunology

Hustvedt, S. (2014). I wept for four years and when I stopped I was blind. Neurophysiologie Clinique/Clinical Neurophysiology, 44(4), 305-313.

Castel, A., Cascón, R., Padrol, A., Sala, J., & Rull, M. (2012). Multicomponent cognitive-behavioral group therapy with hypnosis for the treatment of fibromyalgia: long-term outcome. The Journal of Pain, 13(3), 255-265.

Brain mechanisms of hypnotic paralysis

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DISCLAIMER: is an educational resource for chronic fatigue syndrome (CFS), myalgic encephalomyelitis (ME), burnout and related disorders, and is not giving medical advice. Seek advice from a medical practitioner before making any changes to your life, or if you experience worsening symptoms. CFS is a diagnosis of exclusion, so it is important to rule out other causes for illness.