Michael Sharpe

Professor Michael Sharpe, M.A., M.R.C.P., M.R.C.Psych., is a British professor of psychological medicine at St Cross College, Oxford University and formerly at the University of Edinburgh, United Kingdom. He is a key author of the PACE trial and helped to devise the Oxford criteria as a diagnostic tool for chronic fatigue syndrome (CFS).

Oxford criteria
Prof. Michael Sharpe is author of the Oxford criteria for chronic fatigue syndrome, which is controversial for not excluding patients with symptoms that could be caused by psychiatric disorders, and for excluding patients with a neurological disorder - despite the fact that myalgic encephalomyelitis/chronic fatigue syndrome/post-viral syndrome are all regarded as neurological disorders. The Oxford criteria have been used in a number of influential British studies, including the PACE trial and Deale, Chalder and Wessely (1995), the cognitive behavioral therapy (CBT) study given the highest evidence rating in the York Review of evidence used to justify the recommendation of CBT in the UK's NICE guidelines used by the NHS.

Fukuda criteria for Chronic Fatigue Syndrome
Prof. Sharpe is co-author of the heavily used Fukuda criteria for chronic fatigue syndrome, which was adopted by the CDC.

One functional somatic syndrome
In an influential 1999 article in the Lancet, Sharpe, Wessely and Nimnuan claimed that syndromes such as CFS constitute an “artefact of medical specialisation.” They argued that there’s a large population of patients with multiple medically unexplained physical symptoms (MUS or MUPS) and that it’s mostly the specialist they see that determines their diagnosis. When seen in gastroenterology patients might be diagnosed with irritable bowel syndrome, in rheumatology with fibromyalgia, in cardiology with atypical chest pain, in neurology with tension headache and in an infectious diseases clinic with chronic (postviral) fatigue syndrome. According to Sharpe and colleagues, there is a large overlap between these conditions and they should, therefore, be viewed together as one functional somatic syndrome.

The prevalence of MUS
Sharpe’s research has estimated the prevalence of MUS in neurology and rheumatology clinics at approximately 30%. He reported that MUS patients tend to have more symptoms than patients with a medically explained condition but that symptom count does not adequately discriminate between the two groups.

In collaboration with Chris Burton, Sharpe has studied MUS patients in primary who have been repeatedly (5 times or more in a 5 year period) referred to specialist clinics. Their research indicated this to be a rather small group (0,3% of total patients) but one with a high rate of disability where psychological problems such as depression are undertreated. Sharpe and Burton suggest developing “clinical information systems to remind practitioners that the patient has already had repeated referrals.” They propose a primary care clinic specialized in managing unexplained somatic symptoms with a “holistic” approach that targets symptom-maintaining factors with medication or cognitive behavioral techniques.

Cognitive behavioral model of MUS
In collaboration with Vincent Deary and Trudie Chalder, Sharpe has developed a cognitive behavioral model of medically unexplained symptoms. The model assumes that if persons interpret benign bodily sensations as an indication of disease, they can become locked in an autopoietic cycle characterized by "distress sensitisation"; a reduced threshold for the detection of symptoms. Lack of an explanation is believed to increases anxiety and symptom focus while avoidance of symptoms and symptom-led activity patterns are proposed to lead to further sensitisation through operant conditioning. Sharpe has worked with the Danish team of Per Fink to conduct a randomized trial of CBT for patients with ‘multi-organ bodily distress syndrome’.

Looking for a better name for MUS
According to Sharpe and colleagues, MUS is not an acceptable term to patients and doctors: “It defines the patient's symptoms by what they are not, rather than by what they are, and it reflects dualistic thinking – regarding symptoms as either 'organic' or 'non-organic'/'psychological'.” They suggest that ‘functional somatic disorder’ might be a more suitable alternative as it allows  for an “explanation in terms of altered brain functioning (linking to the term functional imaging) demonstrating that the symptoms are 'real' and yet changeable by alteration in thinking and behaviour as well as by a psychotropic drug.”

From hysteria to functional neurological disorder
In collaboration with neurologist John Stone, Sharpe has studied patients with motor and sensory symptoms—such as paralysis, seizures, and blindness—that are unexplained by disease. According to Sharpe and Stone, these patients are common in neurological practice  and are frequently diagnosed with conversion disorder and in earlier times, hysteria. In a systematic review, they reported that misdiagnosis of conversion disorder and hysteria is uncommon with an average of 4% in studies since the 1970s. According to Sharpe and Stone this indicates that Eliot Slater's influential view that a diagnosis of hysteria is a "disguise for ignorance and a fertile source of clinical error” is a myth and not supported by evidence. They argue that it “was not hysteria that disappeared, but rather medical interest in hysteria.”

Sharpe and Stone have proposed to change the name of conversion disorder into functional neurological disorder “as it is relatively acceptable to patients and is the main term used in other medical specialties to refer to this type of symptom.” They have published a guideline for the detection of functional neurological symptoms which advises doctors to look out for inconsistencies and use Hoover's sign. In contrast, a predominance of symptoms on the left side of the body and ‘la belle indifference’, or a smiling indifference to symptoms, were not seen as signs indicative of functional neurological symptoms. In a long-term follow-up, Sharpe and Stone reported that 83% of their cohort of patients with functional neurogical symptoms still had weakness or sensory symptoms or both after a median of 12 years. Only one out of the 42 patients followe, had developed a disorder which, in hindsight, explained the original symptom presentation. Sharpe, Stone, and colleagues also compared patients with functional weakness to controls with weakness attributable to neurological disease. They found that these had similar levels of disability, although the former were more likely to be out of work because of their symptoms. Patients with functional weakness were less likely to agree that stress was a possible cause of their illness. Similar results were found in a comparison of patients with epilepsy and non-epileptic seizures.

Somatic symptom disorder
In collaboration with Richard Mayou, Sharpe wrote a critique of the somatization disorder diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-4). They argued it should be abolished as it is considered unactable by patients and the psychogenic theory behind it is poorly supported by evidence. As an alternative, they proposed that disorders defined solely by somatic symptoms could more appropriately be classified as functional somatic symptoms and syndromes. Sharpe subsequently became a member of the Somatic Symptom Disorder Work Group for the DSM–5. This resulted in a new category of somatic symptom disorder (SSD), which broadens the former definition of somatization disorder and deemphasizes the centrality of medically unexplained symptoms. Others have criticized the diagnosis of SSD for being too loose and overdiagnosing psychiatric illness in those medically ill.

Bodily symptoms
Sharpe has argued that bodily symptoms should be considered in their own right, not just as manifestations of either bodily pathology or psychopathology. According to Sharpe, there is only a weak relationship between severity of symptoms and severity of pathology, and some symptoms such as fatigue are poorly understood in a purely biomedical model. He has argued that the lack of accepted bodily disease can result in stigma and a morally uncertain position and that this explains the opposition of CFS patients to a psychosocial explanation of their complaints, a hypothesis that is contested by others. Sharpe and colleagues have argued that diagnosis should not be the sole basis of clinical practice and that a focus on prognosis and predictors of outcomes may be more useful.

Fatigue after cancer or a stroke
Sharpe has studied fatigue in patients who had cancer or a stroke. His research indicates that approximately a third of patients have persistent fatigue following cancer or a stroke. Sharpe also conducted SMaRT oncology 1, a large randomized trial that studied the management of depression in cancer patients. The results were reported in The Lancet in 2008 and indicated the intervention was effective in reducing self-reported symptoms of depression, fatigue, and anxiety.

Freedom of information act requests
Michael Sharpe has repeatedly criticised both scientists and patients who have highlighted flaws in his research, or used Freedom of Information Act requests to request the release of unpublished data from his scientific research, including the successful request for the unpublished data from the controversial PACE trial.

Denigration of ME patients
In 2018, a tweet by Sharpe claimed that some Freedom of Information Act requests and scientific criticism could not have been made from patients since they would have been too ill to do so. Sharpe's tweet led to over 100 Australians from the ME/CFS community requesting an apology and pointing out that Alem Matthees had been bedridden for 2 years since winning the PACE FOIA tribunal which led to the release of the PACE trial data, which Sharpe had opposed. Sharpe deleted the tweet as a result of the open letter, which had been signed by many of Alem Matthees's family.

Smearing critics
Prof. Sharpe has repeatedly made ad hominem attacks on critics, including in a 2017 ethics lecture Prof. Sharpe described those who opposed his research, presumably including the scientists calling for the PACE trial to be retracted from The Lancet, as a "co-ordinated campaign" who were "against science", and compared them with climate change deniers.

Denial of illness or disability benefits
Prof. Sharpe has undertaken work for the UK's Department for Work and Pensions, a conflict of interest disclosed in the publication of the PACE trial but not disclosed to participants in the trial. He has also been paid by a number of health insurance companies seeking to deny or minimize disability insurance claims or ill health retirement pensions, including Unum and has repeated claimed that ME/CFS patients are motivated to stay ill in order to continue receiving disability benefits.

Malingering and Illness Deception meeting
Michael Sharpe presented at a Malingering and Illness Deception meeting funded by the UK's Department for Work and Pensions on the topic of distinguishing malingering from psychiatric disorders, a topic that later became a chapter of a book published in 2003 by the same name. Sharpe's chapter gives an example of the case of a woman with Chronic Fatigue Syndrome, which is classified as a not a psychiatric disorder. Other contributors to the book include Simon Wessely, Peter White, Mansel Aylward, all of whom became members of the PACE Trial Steering Committee a few years later.

Retirement from ME/CFS Research
In March 2019 Kate Kelland published in interview with Professor Michael Sharpe in which he claimed to have given up research in ME/CFS due to abuse and harassment from ME activists, however, the article was published less than a week after the publication of Sharpe et al's response to the PACE trial re-analysis by Wilshire et al. The same article was criticized for repeating the claim that Sir Simon Wessely has previously given up research into ME/CFS, despite his continued research publications indicating otherwise.

PACE trial
Prof. Sharpe was one of the three principle investigators in the controversial PACE trial, and a member of the PACE Trial Steering Committee and PACE Trial Management Group. The PACE trial was criticized for using the Oxford criteria developed by Sharpe et al, and Sharpe has been accused of "investigator bias" in relation to the PACE.

Wessely school
Michael Sharpe is often referred to as a "member" of the Wessely school, a group led by British psychiatrist Simon Wessely who have been criticized for their dismissal of biomedical research into ME/CFS, promotion of the biopsychosocial model, and close ties with the UK welfare benefit system and the health insurance industry. Some of the Wessely school have been knowing to make unpleasant comments about patients.

Books

 * 1995, Mayou R, Bass C, Sharpe M. (Eds). Treatment of Functional Somatic Symptoms. Oxford University Press.
 * 1999, Wessely S, Sharpe M, Hotopf M. Chronic Fatigue and its Syndromes. Oxford University Press.
 * 2000, Campling F. and Sharpe M. Chronic Fatigue Syndrome (CFS/ME). The Facts. Oxford University Press.
 * 2003, Mayou R, Sharpe M, Carson A. (Eds). ABC of Psychological Medicine (ABC Series). Wiley-Blackwell.
 * 2003, Distinguishing Malingering from Psychiatric Disorders (book chapter), in Malingering and Illness Deception. New York: Oxford University Press.
 * 2006, Campling F. and Sharpe M. Living with a Long-term Illness: The Facts. Oxford University Press.

Notable studies

 * 1994, The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group (Abstract) - known as the Fukuda criteria


 * 1997, Chronic fatigue syndrome. A practical guide to assessment and management (Full Text)


 * 1998, Doctors' diagnoses and patients' perceptions. Lessons from chronic fatigue syndrome (Abstract)


 * 2002, The report of the Chief Medical Officer's CFS/ME working group: what does it say and will it help? (Full Text)

PACE trial publications:
 * 2007, Protocol for the PACE Trial: A randomised controlled trial of adaptive pacing, cognitive behaviour therapy, and graded exercise as supplements to standardised specialist medical care versus standardised specialist medical care alone for patients with the chronic fatigue syndrome/myalgic encephalomyelitis or encephalopathy
 * Main trial outcome


 * 2011, Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial
 * Other PACE trial publications 


 * 2012, Adaptive Pacing, Cognitive Behaviour Therapy, Graded Exercise, and Specialist Medical Care for Chronic Fatigue Syndrome: A Cost-Effectiveness Analysis


 * 2013, Recovery from chronic fatigue syndrome after treatments given in the PACE trial


 * 2013, A randomised trial of adaptive pacing therapy, cognitive behaviour therapy, graded exercise, and specialist medical care for chronic fatigue syndrome (PACE): statistical analysis plan


 * 2013, The planning, implementation and publication of a complex intervention trial for chronic fatigue syndrome: the PACE trial


 * 2014, Adverse events and deterioration reported by participants in the PACE trial of therapies for chronic fatigue syndrome


 * 2015, Rehabilitative therapies for chronic fatigue syndrome: a secondary mediation analysis of the PACE trial


 * 2015, Rehabilitative treatments for chronic fatigue syndrome: long-term follow-up from the PACE trial


 * 2015, | Longitudinal mediation in the PACE randomised clinical trial of rehabilitative treatments for chronic fatigue syndrome: modelling and design considerations

Publications unrelated to the PACE trial:
 * 2017, Long-term economic evaluation of cognitive-behavioural group treatment versus enhanced usual care for functional somatic syndromes (Abstract)
 * 2019,  Chronic fatigue syndrome and an illness-focused approach to care: controversy, morality and paradox - (Full text)


 * Other publications


 * 2006, Occupational Aspects of the Management of Chronic Fatigue Syndrome: A National Guideline (Full text) External Assessors: Professor Michael Sharpe and Professor Peter White.

Letters

 * PACE trial authors' responses


 * 2011, The PACE trial in chronic fatigue syndrome – Authors' reply


 * 2015, (response) Author's reply - Methods and outcome reporting in the PACE trial


 * 2016, (correspondence) Authors' reply - Patient reaction to the PACE trial


 * 2017, Response to: "Do more people recover from chronic fatigue syndrome with cognitive behaviour therapy or graded exercise therapy than with other treatments?" (Abstract)


 * 2019, The PACE trial of treatments for chronic fatigue syndrome: a response to WILSHIRE et al (Full text)

Media coverage and interviews

 * 2011, Comparison of treatments for chronic fatigue syndrome - the PACE trial - ABC.Net.AU Radio (with transcript)
 * 2013, Chronic Fatigue Syndrome 2 - Lancet TV on YouTube (about the PACE trial)
 * 2015, Chronic fatigue patients criticise study that says exercise can help - Guardian - Oct 28, 2015
 * 2016, Michael Sharpe: Psychiatry was "no waste of a career" - The BMJ Confidential - Aug 10, 2016
 * 2019, Online activists are silencing us, scientists say - Reuters Special Report - Mar 13, 2019
 * 2019, Michael Sharpe on BBC Radio 4 Today programme - Mar 18, 2019 - unofficial transcript
 * ME and the perils of internet activism - The Guardian - Jul 28, 2019

Online presence

 * Twitter
 * PubMed
 * Researchgate

Learn more

 * University of Oxford - Michael Sharpe
 * 2005, A Response to Michael Sharpe
 * 2001, Quotable quotes by Michael Sharpe - Margaret Williams