The Witch, The Python, The Siren and The Bunny

Blog entry posted by alex3619, Apr 23, 2012.

WARNING: Philosophy Alert!

The New Inquisition? Meet Monty Python.

Are you a witch? We will tie your hands and feet then throw you in the water to see if you sink! If you do you were innocent, too bad. If you don't you are a witch, and we have ways to deal with witches. This was a very funny Monty Python skit. Its funny in part because it uses common reasoning - and common fallacies.

"If you have a disability you are faking it" is the implied claim by the current UK government and ATOS. We will cut you off from assistance, and not care if you die. If you don't die you were faking. If you do die, too bad - we need to cut costs and death is a great way to cut costs. Sure the system can be improved. We will get around to it ... eventually. In the meantime lets tweak a few features ... there, we made it better, how can you still be complaining?

Spending a Gold Doubloon to Save a Penny

This is effectively how those with ME and CFS are being treated in the UK, but not just those with neuroimmune diseases or MUSes - most disabled have to face this now. Its a new Inquisition in the worst Monty Python style. If you are disabled then you can work, you just have to be forced to do it. It doesn't matter that you may be dying - dying people have also been assessed as work capable. It doesn't matter if you can't even properly look after yourself or your domicile. It doesn't matter if travel is hugely problematic. It doesn't matter that there are not enough jobs for healthy people. It doesn't matter that most employers are reluctant to hire the disabled and that reluctance will grow to outright hostility if highly disabled people are being forced on them. It doesn't matter that large numbers of people win their appeals to restore benefits - you can cut them off again after only a month, and it can take many months for an appeal. It doesn't matter that all this may cost many times what it saves - they can spin it to sound good. It also doesn't matter that the suicide rate is heading into the stratosphere - thats not genocide, its business as usual.

This is about spending a gold doubloon to save a penny. Its irrational. Its immoral. Its an economic disaster unfolding. Careful rational spending would achieve better outcomes, and it might actually be cheaper to spend more rather than less to get more people off disability incomes.

It can be stopped.

I wonder if I should write a blog comparing the current British Government to the current Syrian Government? How many have died as a result of this? How many are homeless? How many live in torment, fear and profound mistrust of the establishment? This is not business as usual. This is not good government. This is the insane version of economic rationalism - its economic dogma.

The Siren Call.

Something similar is happening with the Dysfunctional Belief Model for CFS.

Sykes has pointed out that the diagnosis of CFS as a mental disorder makes use of what he calls the psychogenic inference. The psychogenic inference uses the following "logic":

"Premise 1. If there is no known physical cause for a
condition, there is no actual physical cause for the

Premise 2. If there is no actual physical cause for the
condition, the cause must be psychological.

Conclusion (The psychogenic inference). If there is no
known physical cause for the condition, the cause must
be psychological."
(p. 312 Functional,Reasons, Neuroscience and the Psychogenic Inference )

Sykes' paper Medically Unexplained Symptoms and the Siren Psychogenic Inference targets the first of these premises. Its not a defensible position. Its also possible, from a strictly logical standpoint, that there is a physical cause that has not been discovered yet. Or that there is a physical cause that has been wrongly dismissed. Or that there are both physical causes and mental causes - so why do they then proceed to ignore the physical?

The psychogenic inference relies either on unexplained symptoms or the lack of a known disorder causing the symptoms. The problem is that most CFS symptoms have physical explanations - you just have to do testing that goes beyond what the hospital system typically provides. So a very real alternative to mental causation is a simple lack of diagnostic and investigatory tests. This is defended on two grounds:

1. It costs too much and often comes up empty, so it is a waste of money.
2. Even if physical problems are found they do not know how to treat it anyway - again a waste of money.

The third through fifth unspoken points are:

3. Its not their problem that the lack of such testing means that patients cannot receive appropriate social support including financial support.
4. Its not their mandate to fund tests to support social claims - OK, maybe it is, but there isn't any funding, what can they do?
5. Its not their fault that they can't treat many of these problems - that requires cutting edge medicine, is often not well validated, requires a better understanding of systems biology which is not taught at medical school, and is often seriously expensive ... where is the money coming from? Who is going to fund this expensive research?

What Sykes does not discuss is the possibility the majority of current psychosomatic medical thinking is wrong. This is a whole other debate, one I will return to later. Sure there are mental issues that cause physical symptoms ... oh, wait, depression is closely associated with physical problems, as is anxiety. It couldn't be that those physical issues are driving the symptoms? No, surely not! :eek: Thats buying into the biomedical model, heresy! Sorry to point it out, but the biopsychosocial model does have a bio- part ... oh, and a social part too.

This is not to refute the importance of cognition, mood and behaviour on modifying brain induced symptoms. The brain is plastic, it can change. The physical issues in the brain might therefore be modifiable by various techniques including CBT - but that doesn't necessarily mean the problem is mental. It might be - or not.

So the basis of a psychiatric diagnosis is this: A patient has a psychiatric reason for their CFS unless a known physical cause is found - in which case even a diagnosis of CFS cannot be made as its diagnosed by exclusion. Therefore by definition, not evidence and reason, if they have CFS then they have a psychiatric illness. Case closed.

Or put another way: If you can't prove your not crazy then you must be crazy. They do not have to prove they are right, only that you can't disprove them - but no you can't do any tests. Its a presumption of craziness without evidence. Oh wait, yes, they use a symptom checklist. Presumed psychosomatic patients have these symptoms. If you have these symptoms you must :oops: therefore have a psychosomatic illness. Its only invalid if a known alternative illness explains the symptoms, like MS. If you have a physical illness with these symptoms that is not understood ... gosh, no, that could never happen! Sorry to point this out, but how many former psychosomatic illnesses are now known to be physical?

The Happy Happy Easter Bunny.

McLaren had this to say about psychoanalysis in his discussion of Popper:

"In 1922, at the remarkable age of twenty, Popper realized that, intellectually speaking, psychoanalysis was on a par with the Easter Bunny: there was nothing anybody could say or do that would force a committed analyst to admit his theories were wrong." (p. 9)

The DBM is a cognitive and behavioural version of the emotive ideas of Freud. It is an unproven model, and the model is not reality. If you always have an explanation, then nobody can prove to you that the diagnosis is wrong.

McLaren has an alternative model of mental disease based on what he calls a biocognitive model. Its just one of the alternatives out there. Functional medicine is also another model ... and by functional they do not mean psychological, but pertaining to the functional relationships between biochemical pathways and physiology, and based on systems biology. Rituximab, a chemotherapy agent, might be shown to be a cure in phase 3 clinical trials. Antiviral and immunological treatments get results up to an order of magntitude better than DBM treatments - so large that I will argue that an RCT is not required to demonstrate effectiveness. Yet somehow the DBM is considered THE alternative. I will get around to addressing the so called "evidence base" for the DBM in a later blog, including methodological flaws. I also intend to discuss the BPS model, and hope to show that it is likely the DBM has been eclectically crammed into the BPS model - but I am still investigating this and will it be well into next year at least before I have much to say on this.

So the DBM is an unproven, counter-factual and irrational position. Yet it is presented as the only evidence based model, with an implication that therefore it must be correct. I would prefer to believe in the Easter Bunny, I see evidence of the bunny every April.

It would be far more rational for the proponents of the DBM to claim that they have an hypothetical and controversial model with little clinical value, that its still experimental, the outcomes are poor, and that alternative models may have validity. No, what? How could they do that? Hmmm, ethics ...

About the Author

I am a long term ME patient with many complications. While I have pushed research advocacy since 1993, I became political around 2009. My current project is a book called "Embracing Uncertainty". Uncertainty in medical science seems anathema to too many doctors. "I do not know" is something more doctors should be honest about.
  1. MeSci
    I was somewhat dismayed to see this page in the New England Journal of Medicine (NEJM): (sorry but it doesn't seem possible to create clickable links in comments).

    This is what it says:

    "For October 6, 2015

    A 19-year-old woman reports that she is having frequent, discrete episodes of chest discomfort, nausea, palpitations, and lightheadedness. The episodes started one month ago, with no clear precipitant. She feels anxious during these episodes and worries that she may be having a heart attack. She has started to avoid leaving the house and doing her usual activities because she is afraid that those activities are precipitating the events. She denies any substance use and does not take any medications.

    Her vital signs and physical examination are normal. An electrocardiogram is unrevealing, and her routine laboratory findings, including a thyroid-stimulating hormone level, are within the normal range.

    Which one of the following diagnoses is most likely for this patient?

    Generalized anxiety disorder
    Illness anxiety disorder
    Acute stress disorder
    Somatic symptom disorder
    Panic disorder"

    I usually like the NEJM, especially their clinical cases where long, complex diagnostic procedures are described and discussed between physicians.

    I don't know how to access the page that gives/discusses the 'correct' answer for these particular symptoms. But it is somewhat worrying - to say the least - that there is no opportunity to say that there could be a physical cause.
    alex3619 likes this.
  2. alex3619
    Kuhn is describing the sociological factors. Popper is about what you need to make science reliable.
  3. Chrisb
    It is just a pity that people seem to think Kuhn more important than Popper with the result that anything goes as long as it is in accordance with the current failed paradigm. "Science" is what it is and no one cares about what it ought to be
    alex3619 likes this.
  4. SDSue
  5. Ren
    A recent find from Ayn Rand's "Anthem" (1937/8):
    Equality 7-2521 (the novella's central character): "The council of scholars has said that we all know the things which exist, and therefore the things which are not known by all, do not exist."
    JaimeS likes this.
  6. alex3619

    It is not clear that there are good cheap treatments for ME, though I argue that good testing will take the guesswork out and massively reduce ongoing administrative costs. Why guess when you can measure?

    The argument you make about financial lunacy is right though, especially when you factor in research on underlying causes of disability and chronic disease. To stop future costs we need better research on biochemical causation of all chronic disease. Social factors may have influence, but the underlying problems have only ever been shown to be physical. Even diagnoses like PTSD are ongoing because of biochemical changes in the brain. In counterpoint to psychobabble about ME, I believe that world events include social ones can trigger disease (not specifically talking about ME here), but its perpetuated by biochemical changes.
  7. Leopardtail
    Penny wise, pound foolish

    When compared with the cost of housing benefit alone, the cost of reasonable tests for M.E. is trivial, the cost of most of the medications is even more trivial if administration does not exceed the cost of the medications.

    Lets say the average rent is $400/month, that every single person with ME is single and gets £150/wk in benefits (ESA/DLA/Other). That is a major underestimate and amounts to £12.5K per year. That approach will likely never lead to improvement in health or return to work. The cost would thus be circa £quarter million /decade with the patient unable to work or socialise.

    By contrast overly comprehensive testing initially would require circa £1000 plus perhaps £400 every 6 months, and drugs might cost somewhere between £150 and £300 per 6months. This treatment in all but the very most severely affected might be needed for six to eighteen months.

    In essence, treating us correctly is far less expensive than paying us to stay at home. The potential saving would add up to more than £100,000 / decade and WE WOULD BE PAYING TAX.

    The current situation is financial lunacy in addition to be inhuman.
  8. Ren
    The psychogenic inference: The origins of life are not known, therefore life is a psychogenic disorder.
    JaimeS, Leopardtail and alex3619 like this.
  9. Don Quichotte
    The single greatest cause of ignorance is the size and complexity of the universe

    The size and complexity of another person's experience is hard enough to understand.

    I think one of the problems is communication.

    How can you communicate what you are experiencing, what you have to deal with, in the most clear and concise manner. How can you make someone who has never experienced something similar understand at least some of it.

    Most people are not evil or hostile, but they are indifferent. They have their own experiences and problems. How do you make them listen, hear and comprehend what you have to say? How could you get them on your side and make them want to help?

    You have to find the way to explain it in words they can understand and at the same time not trivialize it. This is also why it is so important not to use ambiguous words which can mean many things. You also have to realize the associations that certain words may create and the possible misconceptions around them.

    For instance:
    the words "chronic" and "acute" have various connotations.
    Chronic-is in greek-time.
    Acute-is in latin-sharp.
    So, the assumption that goes with those terms is that an acute illness is more severe and intense and therefore relatively short in duration. Whereas a chronic illness is continuous and relatively mild.

    This is a (wrong) mixture of two unrelated variables that define a disease process. One is the duration and the other is the severity.

    In reality, a chronic illness can be a constant and ongoing "acute" illness, with the same degree of severity for years. And an "acute" illness can be both mild and short in duration.

    Also, a disease may not be rapidly progressive, but can still become gradually worse with time, because even if you just add the normal ageing process to an already compromised system, you have much more severe consequences. Another 10% reduction in a person's ability can make a significance difference with regards to independence and mobility.

    By, the same token, a relatively mild improvement can make a similar difference. For instance- A patients that has an average of 50% reserve of respiratory capacity, will be almost asymptomatic when he/she is at 60% and may require respiratory support at 40%.

    This is why proper symptomatic and supportive care can be so important, as even if they lead to only mild improvement the can be cost-effective.

    This is something many people find very hard to understand. They think that if you do so well with such a small "objective" improvement, than you probably could do just as well without it. Or, they think you could do even better with another similarly mild improvement. When, neither is correct.

    The words "chronic disease" and "incurable disease" basically mean the same thing. but, "incurable" is seen very different from "chronic".

    The complexities of a chronic debilitating illness are very hard to understand.
    It takes us (who live with them 24/7) a lot of time to understand, so we should be understanding (at least to some extent) to the inability of others to understand and try to make it simpler for them.
  10. alex3619
    Hi SilverbladeTE, from my rules of thumb:

    27. The single biggest danger to the human race is ignorance. The second greatest cause of ignorance is not lack of education, but the teaching of dogma. Lack of education in reason is the third biggest cause. Lack of education on facts is a mere fourth place.

    28. The single greatest cause of ignorance is the size and complexity of the universe. No mortal can know more than a sliver of a slice of a fraction of the whole. The human race itself only knows a tiny piece of the total.