By David Tuller, DrPH
NOTE: Dr Zachary Grin, a physical therapist in New York City who specializes in functional neurological disorder (FND), left an interesting comment. I am re-posting it up here, with my response:
Dr Grin: “David has misinterpreted the authors. They said “…functional impairment may lead to…”. Functional impairment refers to the limitation/loss of the ability to perform tasks/activities necessary for daily living due to a physical or mental condition. That is universal healthcare language when describing how a health condition impacts a person’s life. In Maeve’s case, she had an impaired ability to eat. Regardless of the cause, we call that a functional impairment or limitation. It has nothing to do with functional disorders. If this misinterpretation was not intentional, he should make a correction.”
My response: Dr Grin makes a compelling point. It certainly is possible that they meant for the phrase “functional impairment” to be interpreted as meaning an impairment of function, no matter what the etiology. But the authors and colleagues with similar views have in multiple contexts made clear that they consider ME/CFS itself to fall into the category of “functional disorder,” along with irritable bowel syndrome, fibroymalgia, and FND. At the inquest, it was also clear that many of those providing care to Maeve thought her eating/swallowing impairment was self-induced and/or psychogenic and/or “functional” in the sense of FND and other “functional disorders”–and not “functional” in the etiologically agnostic use of “functional” suggested by Dr Grin. I think either interpretation of what they meant could be argued. Who knows? Maybe they meant both, intentionally or not.
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Under the editorial leadership of Kamran Abbasi, The BMJ and other journals in BMJ Group have become, at times, mouthpieces for members of the biopsychosocial ideological brigades. That hasn’t been surprising, given his actions during his previous tenure as editor of the Journal of the Royal Society of Medicine.
Under his stewardship, the journal published a piece of crap co-authored by Professor Sir Simon Wessely, a former president of the royal society, and his King’s College London’s colleague Trudie Chalder, the factually and mathematically challenged professor cognitive behavior therapy and one of the lead PACE authors. The 2020 article, Cognitive behavioural therapy for chronic fatigue and chronic fatigue syndrome: outcomes from a specialist clinic in the UK, made causal statements even as it declared that its single-cohort study design did not allow for making causal statements.
When my friend and colleague Brian Hughes, a psychology professor at the University of Galway, and I pointed this out and presented other irrefutable evidence of error, Abbasi declined to take action to correct the public record. We published our critique as a separate article in the Journal of Health Psychology.
Since Abbasi’s ascent as editor in chief of The BMJ, BMJ journals have published some egregious work on ME/CFS and Long COVID. (Not that they were good before.) Most recently, in May, The BMJ, the flagship journal, published what I called “a commissioned propaganda piece” from die-hard biopsychosocial-ists. The commentary, which is called “Patients with severe ME/CFS need hope and expert multidisciplinary care,” touted so-called multi-disciplinary treatment approaches that have no legitimate evidence of effectiveness.
The first author of The BMJ’s invited opinion piece is infectious diseases specialist Alastair Miller, a longtime proponent of graded exercise therapy and cognitive behavior therapy as curative treatments and formerly associated with what was called the Liverpool Chronic Fatigue Syndrome Service. Last summer, during the inquest into the death of 27-year-old Maeve Boothby O’Neill from ME-related complications in Exeter in 2021, The Observer published an offensive and stupid opinion piece by Professor Miller. In the piece, he attempted to hijack the tragedy of Boothby O’Neill’s death to promote his persistent ideological beliefs about purportedly successful rehabilitative strategies.
Another author of the new BMJ article is Paul Garner, also an infectious diseases physician, who has now spent years presenting his N=1 case of recovery from post-viral symptoms as evidence of the power of his strong manly cognitions to cure Long COVID. Per Garner’s claim, this medical turnaround occurred immediately after a phone consultation with someone who sounded very much like a practitioner of the Lightning Process—whether or not that is actually the case.
Like Professor Miller’s piece last summer, the new commentary includes, perhaps not surprisingly, a reference to Boothy O’Neill’s death, in the following sentence: “However, functional impairment may lead to malnutrition and dehydration—described as the cause of death of Maeve Boothby O’Neill, who died in 2021 at age 27.” To be clear: the claim that Maeve’s “impairment” was “functional” rather than driven by ME-related pathophysiological dysfunctions is an unproven theory and contradicts the coroner’s report. The “functional” claim is this lot’s security blanket. But believing in the tooth fairy does not mean the tooth fairy exists.
This desperate plea for relevance from a group of misguided partisans prompted a flurry of rapid responses. So far, 21 have been publicly posted. Sarah Boothby, Maeve’s mother, twice submitted a rapid response. However, it has not appeared. I have posted her comment below. (A version is also posted on Boothby’s LinkedIn page)
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Dear Editor in Chief, Kamran Abbasi
I submitted the following through the BMJ Latest rapid response portal twice, the second time with a request for acknowledgment. As the BMJ has neither published my corrections and criticism nor acknowledged my communication I am writing to you formally for an explanation. Please explain why the BMJ is commissioning and publishing misinformation specifically on Myalgic Encephalomyelitis?
“In commissioning and publishing the opinion piece by Miller et al (BMJ 2025;389:r977) the BMJ failed to fact check and consequently misled its readership on the risk of death from very severe Myalgic Encephalomyelitis (ME). Those interested in medical ethics should note:
Maeve Boothby O’Neill died from ME shortly after her twenty-seventh birthday. She was not the first and has not been the last to die from this devastating illness yet the BMJ made no correction to the claim that Maeve died from malnutrition and dehydration. Dehydration and malnutrition are both easily treatable conditions in Britain. The inquest into Maeve’s death took three years investigating how a preventable death could have been permitted to a young woman who did not want to die, had been actively taking medical advice since the onset of symptoms in 2008, and had consented to three hospital admissions in the seven months prior her premature death in 2021.
It took four years of extensive tests and investigations before Maeve was diagnosed with Chronic Fatigue Syndrome (CFS), by which time she had obtained A* results in Russian, Biology, English and Chemistry at A Level. Such results are not possible without the ability to understand instructions and take advice. Once diagnosed she was under specialist CFS services for eight years, including the Centre of Excellence in Bristol. She meticulously followed the instructions and advice they gave. Maeve never believed she would not recover; she learnt from the bitterest experience how the disease progresses from mild to very severe.
Maeve’s health deteriorated following a mild viral infection from which she (and the rest of her family) appeared to have fully recovered when Maeve was thirteen. Her symptoms steadily progressed to being serious enough that her PE teachers stopped her from joining their lessons; the risk of her being injured was too high.
The facts of Maeve’s death disqualified Miller as an Expert Witness at her inquest. By the end of the three-year inquiry, HMA Coroner was mildly better informed about ME than before the inquest opened. In the process of establishing the facts she confirmed that there are no inpatient services for people with ME anywhere in the UK, either in private or publicly owned hospitals. If the opinions of Miller et al had any efficacy in cases of ME, Maeve would still be alive today.
The Prevention of Future Deaths (PFD) report mentions six national institutions responsible for failing to prevent Maeve’s premature death. These include the National Health Service (NHS), the Medical Research Council (MRC) and the Department for Health and Social Care (DHSC). Failure on this scale can only be remedied by systemic change, which must involve leadership at the highest level.
If a provincial inquest can establish these facts about ME, the BMJ should have little difficulty in doing similar. Failure to correct its editorial stance on this disease, when the international consensus is prioritising patient safety, casts doubt on both the reliability and ethics of opinions from the British medical establishment.”
A shortened version can be found featured in my LinkedIn profile here.
Sincerely
Sarah Boothby
I think it’s disgraceful for the journal not to publish a response submitted by Maeve’s mother – that she hasn’t been allowed to respond to the authors’ opinion on her daughter’s death so that the world can judge whose words best reflect the facts of the case as we know them. Theirs is undeniably an opinion piece so on what basis is the journal denying her request for her opinion to be made clear?
To my mind, replacing just one word – ‘impairment’ for ‘dogma’ – in the text of the published article would help enormously. I believe that functional dogma is both risking and causing enormous harm to patients across medical specialties and I still wonder whether the contents of the January 2021 issue of the journal “Clinical Medicine” (see here https://www.sciencedirect.com/journal/clinical-medicine/vol/21/issue/1)- a journal of the Royal College of Physicians – could possibly have swayed the opinions and decisions of any of the doctors/physicians involved in Maeve’s care.
No right to reply, what a disgrace. The stubborn bias of a few is severely affecting progress which also shows intentional harm to both Maeve and her parents. It’s abusive. I suggest they consider CBT and NLP for their own behaviours and attitudes towards this disease and stop impeding progress in areas of science that are proving this outdated model as incorrect.
How can an infectious disease clinician be so uninformed on the recent science of post viral disease? I’d be embarrassed.
Thank you Dave for allowing some necessary balance here so others can make an informed decision.
We should start referring to them as BPSholes
David has misinterpreted the authors. They said “…functional impairment may lead to…”. Functional impairment refers to the limitation/loss of the ability to perform tasks/activities necessary for daily living due to a physical or mental condition. That is universal healthcare language when describing how a health condition impacts a person’s life. In Maeve’s case, she had an impaired ability to eat. Regardless of the cause, we call that a functional impairment or limitation. It has nothing to do with functional disorders. If this misinterpretation was not intentional, he should make a correction.
In the context in which ‘functional impairment’ was used in this case, particularly the preceding sentence, I’d say that it’s meaning was unclear. It may well be universal medical lingo for the inability of patients – any patients – to maintain some aspect of normal human functioning but could the authors have used it there to convey the other meaning of ‘functional’, or two meanings maybe? To me, the use of the word ‘however’ suggested that it was somehow linked to the previous sentence and it was for the reader then to try to interpret how that ‘however’ was meant.
Perhaps it wasn’t such a good idea to employ a term – ‘functional’ – for supposedly psychogenic/psychosomatic conditions that is also used in universal medical lingo to convey a different meaning? But then I understand that it was chosen for that purpose because it was found to be more acceptable to patients, I guess because it confused them into thinking that they weren’t being gaslighted by their doctors. Time for yet another name change, perhaps?
I’d add that the term “functional” confused me for a few hours when a neurologist told me that he thought I had functional neurological disorder. As a scientist by training, I was imagining that the term referred to a disorder of function in the body rather than a structural abnormality that might show up on a scan, (even though there were abnormalities on my scans), and my mind instantly leapt to possible biochemical or physiological problems and I could see how that could potentially make sense. It was only when I got home and accessed the website that he’d directed me to that I realized that I’d been misled. When I next saw the neurologist, I politely gave him a piece of my mind. His response was to label me with medically unexplained symptoms instead.
That was many years ago and I understand that there’s now a brain network theory for FND. I can’t imagine how a disruption to the brain’s networks couldn’t involve a problem with the biochemistry/physiology of the brain and yet the authors of the BMJ article didn’t suggest that ME/CFS could be a pathological/somatic disease with perhaps a physiological or biochemical basis. I guess then that they either don’t see ME/CFS as a “functional” (I mean FND-style “functional”) condition or they don’t subscribe to the brain network theory, assuming that brain network theory proponents do accept that malfunctioning biochemical and physiological processes would be involved with that. On that subject, this recent 2025 paper -https://www.sciencedirect.com/science/article/pii/S2213158225000373 .
is interesting. I must confess that I haven’t trawled through the responses to the article to see if anyone has suggested to the authors that to be in line with the FND brain network theory for functional conditions, ME/CFS, if also considered (psychogenic-style) functional, should probably be viewed as a somatic pathological condition.
Dr Grin makes an interesting point. It certainly is possible that they meant for the phrase “functional impairment” to be interpreted as meaning an impairment of function, no matter what the etiology. But the authors have in multiple contexts made clear that they consider CFS or ME/CFS itself to fall into the category of “functional disorders”–the same use as “functional” as in FND. At the inquest, it was also clear that many of those providing care to Maeve thought her eating/swallowing impairment was indeed “functional” in the sense of FND and other “functional disorders.” So I think what exactly they meant is unclear.
Disagreements of this sort goes deep all the way to the scientific bone (Physicists disagree wildly on what quantum mechanics says about reality, Nature survey shows).
@Zachary Grin:
Tuller indeed seems to have misinterpreted the term “functional impairment”.
However, the terminology is weird. ME/CFS is regularly described as a “functional disorder” in certain academic circles. “Functional disorder” does imply a disorder with no driving decease or pathology. So I do understand how this misunderstanding happened.
The terms “functional disorder” and “functional neurological disorder” are ridiculously opaque, non-intuitive and misleading, to such a decree that it’s hard not to suspect that this is intentional. They should be called for example “psychogenic functional disorder” and “psychogenic functional neurological disorder”.
@Zachary Grin: Your are a practitioner in the field. Please be a proponent for clarity and stop using the misleading terms “functional disorder” and “functional neurological disorder”, and encourage other people in the field to do the same. Increased clarity will benefit the field.
As a patient, I can’t escape the impression that the terms “functional disorder” and “functional neurological disorder” are deceptive and dishonest. You and your field are not helped by patients thinking that you are deceptive and dishonest.
Rearranging & adding words greatly changes meaning. I’m not reviewing who said what but in general each of the following mean different things:
1) disorder that affects daily functions;
2) disorder that affects bodily functions;
3) functional disorder;
4) functional neurological disorder.
We may get distracted by confusions.