Metaphors and medically unexplained symptoms - Lancet

[Hutan]

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61530-6/fulltext
The Lancet
Metaphors and medically unexplained symptoms
Eben S Schwartz

Argh, waffle about deluded people with trivial psychomatic symptoms looking endlessly and in vain for significant biological causes.

There is a valid point that normal human states are sometimes being pathologised (sadness equals depression; valid fearfulness and uncertainty equals anxiety disorder.

Looking on the bright side, there is an air of defensiveness

But fair enough: history suggests that some conditions we think are psychological today will be medically explained in the future. Still, I continue to believe that most patients with persisting medically unexplained symptoms have just fallen down the rabbit hole of the medical complex. Many are on a crusade for an illness that is too literal and almost holy in its promise of deliverance, yet will never be associated with an abnormality that robbed them of their sense of normalcy.

An explanation can bring more relief than any treatment because the wish for a reason is more powerful than the desire for a cure.
/QUOTE]

 

[GracieJ]

E-mail address for the author is on the article.

Hard to believe this is written today.

His lab friend is describing early signs of migraines developing. I wonder...

Go, team.

 

[TiredSam]

Estimates of the prevalence of medically unexplained symptoms range from 5–65% in primary care to 37–66% in specialty clinics.

My first GP estimated that 95% of his patients had stress-related symptoms that would go away when they realised what was causing the stress. He saw his job as mostly holding people's hand. He was a terribly nice chap, if a little vague. What was causing my stress was a 6-week headache and his attitude, so I never went back.

People become patients when they bring medically unexplained symptoms to the doctor. Most are sufficiently comforted by the bleached rituals of the medical encounter to return home as they came in: essentially well.

How does he know that the patient has been sufficiently comforted? Because they don't come back? Feeling sufficiently comforted wasn't the reason I never went back to my doctor, but if he wants to chalk it up as another success that's up to him. Another example of the self-delusion of psychobabblers - "well no-one ever comes back so I must be curing them".

Even in so-called hard science and medicine, metaphors are stuffed like old newspapers into the gaps of our understanding as if to cut the draft of the unknowable. Chemical imbalance seems less metaphorical to us than refrigerator mothers, but I think our predecessors will see it as not such a leap from bad humours.

I don't even know where to start with this. He is concerned that those who devised cruel labels for the parents of autistic children in the past may not approve of the phrase "chemical imbalance", which he thinks is a metaphor for the "unknowable"?

I suspect it would suit him for the causes of many symptoms to remain "unknown" for as long as possible, so he can continue lazily applying metaphors, dismissing patients and feeding his ego instead of doing some real work. It'll be interesting to hear what his successors make of him and his views.

Can't read any more of his flowery language and pseudo-philosophical ramblings. How on earth stuff like that get accepted for publication in the lancet is beyond me.

 

[Scarecrow]

How does he know that the patient has been sufficiently comforted?

Because he's taught that that will be the case if he does and says the right things.

There's a line in my medical file the pretty much verbatim goes "I reassured the patient. The patient was reassured." The context was that my GP was reviewing my blood tests shortly after I'd had to withdraw from university on the grounds that I couldn't sustain any activity for more than half an hour and I could barely read. There was no sign of inflammation or any other abnormality in my bloods, ergo there was nothing seriously wrong and nothing for me to worry about. So if he reassures me of that, I will in turn be reassured and in no time at all I'll just jump up and get back to normal.

My thoughts at the time were not "how reassuring" but "you're an idiot". I just kept it to myself.

Edited to add: this whole stupid way of dealing with patients of course just increases or, indeed, causes anxiety. I'd say that I had every justification to be anxious about my condition before that consultation. How much more anxiety forming to know that there is something very badly wrong with you but for your doctor to not recognise it and dismiss it?

 

[sarah darwins]

Still, I continue to believe that most patients with persisting medically unexplained symptoms have just fallen down the rabbit hole of the medical complex. Many are on a crusade for an illness that is too literal and almost holy in its promise of deliverance, yet will never be associated with an abnormality that robbed them of their sense of normalcy.

What's this doing in The Lancet? Even the title belongs in the International Journal of Cultural Studies (alongside this month's articles — Constructing a digital storycircle: Digital infrastructure and mutual recognition and The pain and pleasure of roller derby: Thinking through affect and subjectification).

And while we're deconstructing our narratives, I demand metaphorical clarification: have we fallen down a rabbit hole or gone on a crusade? It can't be both. No one ever went on a crusade down a rabbit hole. Except maybe a ferret. Are we ferrets? Is this our 'abnormality'?

And who's to say what's normalcy? Or even normality?

And who the hell is Eben S Schwartz? Is that even knowable?

Next week — Medically Unexplained Symptoms and the Semiology of Oblivion: An Existential Perspective.

 

[TiredSam]

No one ever went on a crusade down a rabbit hole.

It's Alice in Wonderland.

 

[worldbackwards]

And who the hell is Eben S Schwartz? Is that even knowable?

It's medically unexplained.

 

[Scarecrow]

And who the hell is Eben S Schwartz? Is that even knowable?

I know I shouldn't have taken that question literally but.................well..............rated #42 of 47 psychologists in Waukesha, Wisconsin on the Rate MDs website (tagline 'doctors you can trust').

https://www.ratemds.com/doctor-ratings/3474412/Dr-EBEN+S.-SCHWARTZ-WAUKESHA-WI.html

 

[sarah darwins]

I know I shouldn't have taken that question literally but.................well..............rated #42 of 47 psychologists in Waukesha, Wisconsin on the Rate MDs website (tagline 'doctors you can trust').

https://www.ratemds.com/doctor-ratings/3474412/Dr-EBEN+S.-SCHWARTZ-WAUKESHA-WI.html

There are 47 psychologists in Waukesha, Wisconsin???

 

[jimells]

My first GP estimated that 95% of his patients had stress-related symptoms that would go away when they realised what was causing the stress.

I wonder how many of his patients "went away" because they died.

 

[jimells]

And who the hell is Eben S Schwartz? Is that even knowable?

It must be a satire. Certainly "a real doctor" would never write this kind of rubbish...

 

[JaimeS]

There are 47 psychologists in Waukesha, Wisconsin???

One for each of the inhabitants.

 

[Snookum96]

 

[Sidereal]

Her job entailed looking at diseases under a microscope in a hospital laboratory. At some point she started to have vague symptoms. Nausea, fatigue, malaise. She looked that up online. She began to obsess about food. Dizziness, ringing in the ears, back pain. She saw her doctor repeatedly and underwent scans and blood tests—the results were always normal. Jaw tightness, shortness of breath, sleep problems. She had an itch on her arm and was certain that meant pancreatic cancer. A persistent lump in her throat was suspicious for a thyroid malignancy. Trips to the emergency department yielded more normal test results and a prescription for lorazepam. Headaches, vertigo, feeling more emotional—“A brain tumour could cause all of those things”, my friend said.

Sounds like dysautonomia to me.

 

[Esther12]

One day there will be an article with a title like this that turns out to be really interesting. I'm pro-actively preparing for this day in order to protect from the psychosomatic breakdown that the shock would otherwise induce.

 

[alex3619]

And who's to say what's normalcy? Or even normality?

Normalcy cannot be defined. This has been attempted again and again, but all definitions are problematic.

 

[alex3619]

When patients ask a doctor if it could be X, because of Y symptoms, they are looking for answers. The doctor often cannot provide. If the doctor is sceptical that it might be X, this may be appropriate. What is not appropriate is ignoring the Y symptoms.

Take the case of ME. The IOM report, for all its limitations, did point out that the five primary symptom clusters are all objectively measurable. So any claim that ME or CFS or SEID is about medically unexplained symptoms is dubious at best, and absurd at worst. There is a confusion here. The disease is not explained, but the symptoms are indeed explained. MS, diabetes and a host of other diseases are not explained either. Yet we do not doubt the measurable physiology of those diseases.

I think many MUSes are the same - real and measurable symptoms are ignored, but with primacy being given to the cause not the symptoms. The cause is unknown, so the symptoms are ignored.

 

[sarah darwins]

I think many MUSes are the same - real and measurable symptoms are ignored, but with primacy being given to the cause not the symptoms. The cause is unknown, so the symptoms are ignored.

Exactly. I thought part of that anecdote about the lab worker was rather alarming:

At some point she started to have vague symptoms. Nausea, fatigue, malaise.

I can't see that there's anything vague about nausea. It's something that warrants investigation, especially in someone who is working in a hospital pathology lab.

 

[Valentijn]

It can't be both. No one ever went on a crusade down a rabbit hole. Except maybe a ferret. Are we ferrets?

It sounds like something Lemmiwinks might do. So I vote for "gerbils".

 

[Woolie]

I like this part:

I talked to her about butterflies in the stomach, contagious yawns, that itch in your throat during a quiet lull at a concert after someone else has cleared his. The placebo effect and the nocebo effect. The fight or flight response. The correlations between stress and immune function, wound healing, and heart disease.

Looks like the writer truly believes in the power of placebo. I guess that's what they're taught about there. They don't realise that a large part (perhaps all?) of the placebo effect is a self-report artefact.

Ditto for "the correlations between stress and immune function, wound healing, and heart disease". Granted, the writer might not be fully qualified to evaluate the (very poor) research on this topic, but then if you're writing an article like this, you need to know your own limits.