This is a great post. I’m very interested in your recent articles on long covid!

I continue to think that the distinction between ‘organic’ and ‘psychosomatic’ is not useful. To call someone’s syndrome psychosomatic implies that it is less real than an organic disease, but all it really means is that the biological basis of the condition is not understood well enough to detect it using existing tests. As long as you assume that a person with a psychosomatic condition isn’t lying about their experience, there must be a biological explanation for their fatigue. (There is no other option; the structure and function of your brain is responsible for everything you experience.) You mentioned some potential mechanisms in your previous posts (e.g. the false fatigue alarm), but whatever the cause of the problem, I think that reiterating to patients that their ‘psychosomatic’ chronic fatigue is biological (even if it can’t be detected with available tests) will go a long way to making patients with undiagnosable syndromes feel less stigmatized and demoralized.

I agree that depression is often comorbid with chronic fatigue, and that tackling the depression component might be helpful for many people. It occurs to me that encouraging patients to think of their chronic fatigue in a similar way many patients are encouraged to think about their depression. For example, CBT explicitly uses expressions like “when you’re depressed, your brain tricks you into believing you’re worthless by focusing only on negative types of self-evaluation.” Clearly, it can be helpful to conceptualize depression as a separate agent that you outsmart using strategies like CBT. The fact that the patient might be able to exert some control over their symptoms is considered empowering, and not a reason to discount to reality of their suffering. Conversely, if a patient doesn’t respond to CBT it doesn’t mean that the patient didn’t try hard enough –they are just non-responders to that particular therapy.

I can imagine that this attitude toward depression might be helpful if applied to chronic fatigue. If people were encouraged to think of their fatigue as (at least partially) a false alarm, it would open their minds to the possibility of using psychological strategies to re-train the brain’s fatigue sensor. I agree that CBT is a good basis for such a therapy, and I would love to see an RCT that tested the efficacy of this type of CBT for chronic fatigue and/or Long covid symptoms. :)

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