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Conservation of Confusion

Blog entry posted by anciendaze, Sep 14, 2013.

Medical research has any number of difficult aspects, and the sociology of research is one of them. It would be nice to have fundamental laws which would deal with various conflicts based, not on subject matter, but on known characteristics of human beings which frustrate investigation of much simpler problems, like who failed to make fresh coffee when they took the last cup.

I'm going to take the plunge and propose one: conservation of confusion. This means that any well-funded research must not remove the need for further research, and must avoid changing the structure of organizations created to deal with the current muddle.

Here is a modest example on the subject of fibromyalgia: No Consistent Difference in Gray Matter Volume between Individuals with Fibromyalgia and Age-Matched Healthy Subjects when Controlling for Affective Disorder.

That pretty conclusively shows that there is no need to investigate the brains of those fibro patients who clutter your office, except those who have mental problems, and should therefore be referred to a psychiatrist, doesn't it? One thought immediately struck me when I saw that title: I'll bet they ended up with fibromyalgia patients who were younger and healthier. An examination of their data confirmed my guess, at least as far as this was possible.

Exactly how you measure the intensity of perceived pain is a long-standing conundrum. The idea that people subject to intense chronic pain become depressed is not exactly radical, and has good support in cases where there is little reason to infer prior mental illness. Let me simply say that the hypothesis that they were systematically removing the patients who were sickest from this study was not rejected. Take a moment to reflect on the effect of removing the sickest patients from the study of infectious diseases, e.g. poliomyelitis without paralytic cases.

What I can tell you about research on chronic pain and changes of volume of various parts of the brain is that this stands up well in other studies with no particular axe to grind concerning fibromyalgia. Here's one which includes patients with severe pain from osteoarthritis of the knee. (To the best of my knowledge osteoarthritis has not been attributed to mental illness, though I am open to correction on the subject.)

This is not to say that severe mental illness does not induce changes in volume of parts of the brain, even when current research finds no organic brain disease. Here's research on major depressive disorder. If asked I'll add research on schizophrenia and bipolar illness.

This could be interpreted as evidence that perceived pain in major depression is every bit as real as pain in osteoarthritis, based on an objective measure of pain. Another approach would be to argue that all the most serious mental illnesses, those specifically requiring referral to psychiatrists, even involuntary commitment, has organic causation. This might naturally lead to a groundswell of support for efforts to find these causes, relieve suffering and reduce public expenditures for disability and lifelong treatment of incurable conditions. Any high-level administrator will instantly detect the danger of any such finding: it would violate the principle stated above.

Historically, this principle has served generations of medical researchers well, even as patients suffered. Here's an example at odds with the triumphalist view of medical progress presented medical textbooks: The Atavistic Degenerative Diathesis: of Tuberculosis. Please take a moment to reflect on the role this played in the fight against tuberculosis, separate from its effect on wider concerns. (I've explained some of the arguments and references used here.)

The term "diathesis" means a predisposition to an illness, and is not fundamentally evil, but it has certainly been used for purposes few medical people today are willing to publicly endorse. You can find research looking for a "depressive diathesis" not too far from the present. That first study referenced above might serve as a basis for exploring the depressive diathesis in fibromyalgia.

See how this fits the stated principle?
anciendaze

About the Author

As the name suggests, I am old and dazed. The avatar illustrates my rule of thumb: "Hang on! This ride isn't over."
  1. natasa778
    Talking about correcting the perversity ... the hopeless optimist in me likes to think that the freshly announced NIMH Research Domain Criteria (RDoC) MIGHT begin to do just that (emphasis on BEGIN, as in its current form it is far from progressive enough). Of course not to say that it itself could easily get perverted or watered down, for example by getting bogged down in brain imaging or genetics, but it does look like at least someone has realised that the symptom-based approach to 'mental illness' does not benefit the patient ... http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml
  2. anciendaze
    Don't underrate the human capacity for self-deception.
  3. Erik Johnson
    Those of a perverse nature care more about carrying on what they do than prudent ones care to put a stop to them.
    . don't want to find anything that could possibly interfere with their hypothesis, and control the input by careful selection of their study group.
  4. anciendaze
    This may not be a deliberate decision, in the form you have cast it. The sociological aspects of making a change in the flow of patients between different specialists, and particularly the wastebasket of psychiatry, can militate against a course of action without actually making anyone involved aware that they are pulling a fast one on patients. Awareness of anything except what you are doing, and your direct interactions with people around you, is surprisingly rare.

    At some point the sheer perversity of sending people with objective evidence of organic changes in the brain (including depressives, schizophrenics, bipolar sufferers) to doctors who can only talk to them and prescribe for limited symptomatic relief, while handling those who do not have atrophy of the brain in normal medical contexts, where we at least talk about cures, ought to impress someone as deserving correction.
  5. Erik Johnson
    I can totally substantiate this concept.
    If CFS researchers wanted to solve CFS, they would ask "How did this syndrome start? What set of circumstances set this in motion, what did they know, and when did they know it?"

    The fact that no CFS researchers have done so, univerally making the decision that solving the original evidence base is not on their agenda, shows us that perpetuation of the mystery is their primary goal.