Enck, P, Mazurak, N · Neurogastroenterology and motility · 2018 · DOI
This study reviewed research showing that infections can trigger long-lasting functional disorders—conditions where the body doesn't work properly but standard tests appear normal. The authors propose that these disorders start from biological changes (like immune dysfunction or altered gut bacteria) caused by the infection, and that psychological factors develop as a result rather than being the root cause. This challenges the common belief that such conditions are mainly psychological or social in nature.
For ME/CFS patients and researchers, this framework is significant because ME/CFS often follows viral infections and presents as a functional disorder with multisystem symptoms. The study supports investigating underlying biological mechanisms—immune dysregulation, mitochondrial dysfunction, microbiome changes—rather than attributing symptoms primarily to psychological factors, which may redirect research and clinical attention toward treatable biological causes.
This scoping review does not establish causation or provide new experimental data; it synthesizes existing literature and proposes a hypothesis rather than testing it. It does not prove that psychological factors play no role in disease expression or prognosis, only that they may be secondary rather than primary. The applicability to ME/CFS specifically is not directly addressed and would require targeted investigation.
About the PEM badge: “PEM required” means post-exertional malaise was an explicit required diagnostic criterion for participant inclusion in this study — not that PEM was studied, observed, or discussed. Studies using criteria that do not require PEM (e.g. Fukuda, Oxford) are tagged “PEM not required”. How the atlas works →
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Primary citation
Enck, P & Mazurak, N (2018). The "Biology-First" Hypothesis: Functional disorders may begin and end with biology-A scoping review.. Neurogastroenterology and motility. https://doi.org/10.1111/nmo.13394
BibTeX
@article{mecfsatlas-enck-2018-biology-first,
author = {Enck, P and Mazurak, N},
title = {The "Biology-First" Hypothesis: Functional disorders may begin and end with biology-A scoping review.},
journal = {Neurogastroenterology and motility},
year = {2018},
doi = {10.1111/nmo.13394},
note = {PubMed: 29956418},
url = {https://www.mecfsatlas.com/evidence/enck-2018-biology-first},
}Atlas snapshot reference
ME/CFS Atlas. Generator v1 / Scanner v1.4 / policy v0.1. Accessed 2026-05-30. https://www.mecfsatlas.com/evidence/enck-2018-biology-first
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