Going Around in Circles with Long COVID

Readers of Social Science Space may recall that Dr. Jeremy Devine suddenly became the best-know psychiatry resident North America when he published a guest essay in the Wall Street Journal, asserting that Long COVID – a series of distressing sequalae following otherwise apparent recovery from COVID-19 – is actually a “psychosomatic-symptom disorder” that is “largely an invention of vocal patient activist groups.” In a later interview with London’s Sunday Times, Devine explained that Long COVID stems “from a subconscious desire to be sick” that may be “rooted in depression and anxiety,” for which he blamed  what he called “the chronic fatigue lobby.”

Devine is not alone in his views, which have been quoted uncritically in the New Yorker and elsewhere. Writing in medical journals, other psychiatrists have made comparable statements about the supposed psychogenic origin of chronic fatigue syndrome (also called myalgic encephalomyelitis or ME/CFS), claiming that patients are seeking to maintain the “benefits of the sick role.”

That got me thinking about how a primary care doctor with those beliefs might interview a new patient. Hence, the following imaginary conversation.

Patient: Good morning, doctor. I had COVID-19 about six months ago, but I still feel terrible, with headaches, dizziness, and brain fog. Do you think I might have Long COVID?

Doctor: I am terribly sorry. Your tests are all negative, however, so it looks like you have fully recovered from the virus.

Patient: I sure don’t feel recovered. There are days when I can barely move because of the fatigue.

Doctor: That can be caused by what we call catastrophizing. You could be concentrating too much on your symptoms, instead of recognizing that you are feeling better.

Patient: But I am not feeling better. I feel awful.

Doctor: That is probably because you have been paying attention to vocal patient activist groups. They have unfortunately spread all sorts of invented ideas about the aftermath of COVID-19.

Patient: I have never heard of any patient activist groups, so how could they affect my symptoms?

Doctor: Good question. Some of their influence has been spread by the chronic fatigue lobby.

Patient: Really? A lobby? I have never heard of them, either.

Doctor: Let’s get back to your psychosomatic disorder.

Patient: Psychosomatic disorder?  I came her for help with body aches and brain fog.

Doctor: Yes, but those can be caused by your anxiety and depression.

Patient: Wait a minute. Wouldn’t I know it if I had anxiety and depression?

Doctor: No, you wouldn’t.

Patient: Why not?

Doctor: Because you are misinterpreting your symptoms due to a subconscious desire to be sick.

Patient: I am not sure I can agree with that.

Doctor: Oh, more evidence of depression.

Patient: I really don’t think I’m depressed.

Doctor: Even more evidence.

Patient: So, no matter what I say, it will just prove that you’re right about depression?

Doctor: Exactly. Listen, do you want to get better or not?

Patient: Yes, of course I want to get better. What do you recommend?

Doctor: I would like to refer you to a psychiatrist.

Patient: Really? What would a psychiatrist to for me?

Doctor: They would get you started on cognitive behavior therapy and a graded exercise program.

Patient: But exercise has been making me feel even worse.

Doctor: That’s because you haven’t been doing enough of it. You need to push yourself a little more each day.

Patient: Seems risky. Is there any research specifically supporting graded exercise for people with Long Covid?

Doctor: No, but psychiatrists have been prescribing it for ME/CFS for decades.

Patient: Oh, I have read about that. I guess the conditions are similar, but don’t ME/CFS patients say that exertion makes them relapse?

Doctor: They say it does, but only because they are holding onto the benefits of the sick role.

Patient: Don’t you have a less patronizing answer than that?

Doctor: Sure, you could call it an illness without disease.

Patient: What does that mean?

Doctor: It means they are having the experience of illness, but there is no medical cause for it.

Patient: How does that explain their symptoms?

Doctor: They have become deconditioned. You don’t want that to happen to you, do you?

Patient: Can’t people tell the difference between being sick and being out of shape?

Doctor: Not if they have anxiety and depression.

Patient: Now you are becoming circular. You begin by assuming they have a psychosomatic symptom disorder, and then you keep relying on the same disorder to prove you were right in the first place. Don’t you see how patients might have a problem accepting that?

Doctor: Not after they realize how compassionate I am.

Patient: It sounds like you think you can read minds.

Doctor: Yes, of course. After all, I am a doctor.

On October 13, 2021, the Journal of the American Medical Association reported that “more than half of COVID-19 survivors” experienced continuing symptoms, including fatigue and mobility impairments, six months after “recovery.” The authors of the study warned that these after-effects are occurring “on a scale that could overwhelm existing health care capacity, particularly in low- and middle-income countries.”

Steven Lubet, JD, was diagnosed with chronic fatigue syndrome (ME/CFS) in 2006.