Psychogenic explanation of physical illness: time to examine the evidence

[Kati]

Carolyn Wilshire is a psychologist and also a university senior lecturer who wrote a polished response to a PACE trial paper earlier this year, which can be found here

She wrote a new paper (which I haven't read, but I am sure it is good) 40 pages long, available here:

http://www.researchgate.net/publica...physical_illness_Time_to_examine_the_evidence

She is seemingly on the same side as James Coyne is which is very good news for us.

 

[Never Give Up]

Wow!

 

[Hip]

Absolutely brilliant. I have been waiting for years to see a good scientific paper critical of psychogenic explanations of physical illness. I like these excerpts:

This article examines whether such psychological causal explanations have evidential support.

We ask: What sort of evidence would be required to provide positive support for such an explanation? We see no reason why a lower standard of evidence should apply to a psychological than to a medical explanation.

This is a key point: the fact that psychologists and psychiatrists who deal in psychogenic explanations have far lower standards of evidence compared to medical scientists who study biochemical mechanisms of disease.

Clearly, psychological causation cannot be demonstrated by the mere absence of a confirmed disease diagnosis – not unless we assume our current knowledge of disease and its markers is 100% perfect.

Spot on. This in a nutshell is the fundamental flaw in psychogenic explanations: the erroneous and baseless assumption that because current medical technology cannot find very much physically wrong in the patients, their physical symptoms must be caused by psychological factors. This ridiculous assumption needs to be purged from medical science.

 

[barbc56]

Thanks!

 

[Cheshire]

Yes, this paper is a very solid critique of the psychogenic theory. There are several points that deserve to be highlighted, it's a very long and complex article.

It tackles the lack of science to back up this theory, the flaws and limitations of the research upon which it is built, the arbitrary choices that are made (this disorder is psychogenic, this one isn't), the harm it does to patients.

Complete, dense and empathetic!

Some quotes (not the best ones, but I must read the whole text again):

Finally, unlike many other psychological constructs, which have measurable affective, cognitive and physiological/somatic components, the measurement of somatization is based entirely on somatic complaints. Its status as a “psychological” construct rests entirely on indirect inference.

Studies that have compared secondary gain rates in suspected psychogenic illness with well-matched groups with
neurologically confirmed disease have failed to find differences in their incidence (Chabrol et al., 1995; Gould, Miller, Goldberg & Benson, 1986). A further problem is that secondary gains are often evaluated without taking into account the associated losses, which
may be wide and devastating (e.g., loss of financial and personal independence, loss of social contacts, leisure pursuits, and so on). Clearly, gains must significantly outweigh losses if they are to be motivating for the patient [...]
This case illustrates how readily secondary gains can be found – even in severe organic illness - and the dangers of seeking them after a psychogenic diagnosis has been made

There may also be serious risks at the level of the individual patient. Above, we discussed the possibility that a psychogenic diagnosis may impose an additional psychological burden on the patient. Indeed, from the moment such an explanation is considered, the patient’s feelings and beliefs about their illness are recast as dysfunctional and become targets for “correction” by those claiming greater insight. We need to be very sure we do in fact have greater insight. A psychogenic interpretation also carries implications about the patient’s own responsibility for their continuing illness. Behavioral therapies may further reinforce that message, and a failure to respond to therapy may sometimes even be blamed on the patient (“The patient’s own psychopathology interferes with treatment”: Harden, Burgut & Kanner, 2003). Again, we need to be very certain our treatments are effective before we jump to such conclusions.
Psychogenic diagnoses also influence the way patients are viewed by others. Studies using artificial patient vignettes suggest that a patient’s complaints may be rated as less serious if they are believed to be psychogenic, and the patient is more likely to be characterised negatively

 

[Kati]

Yes, this paper is a very solid critique of the psychogenic theory. There are several points that deserve to be highlighted, it's a very long and complex article.

It tackles the lack of science to back up this theory, the flaws and limitations of the research upon which it is built, the arbitrary choices that are made (this disorder is psychogenic, this one isn't), the harm it does to patients.

Complete, dense and empathetic!

Some quotes (not the best ones, but I must read the whole text again):

Thank you so much @Cheshire, the last quote is very powerful and resonnate with me a whole lot.

 

[Hutan]

Carolyn Wilshire is a psychologist and also a university senior lecturer who wrote a polished response to a PACE trial paper earlier this year, which can be found here

She wrote a new paper (which I haven't read, but I am sure it is good) 40 pages long, available here:

It is very good.

The points made are common sense and are issues we often talk about here (e.g. sample size; suitable controls; recall bias; problems with self reporting; researcher bias with lack of blinding). They are nicely supported with data and references. And while the points are common sense, clearly medical professionals who are applying, promoting and researching psychogenic diagnoses need much more exposure to them.

There are quite a few typos in the paper though. This may make it easier for the people who most need to hear its messages to dismiss it. (ie 'the sentence doesn't make sense, maybe the analysis was sloppy too')

It is odd as clearly a lot of time has been spent doing all the data gathering and analysis and the content is great; it just needed an hour of editing to finish it.

Hopefully there will be a more polished version of the paper later as it is one I would like to have in my armoury when dealing with doctors who are still stuck on the idea that behavioural and personality issues are the cause of ME/CFS.

(Fingers crossed my typos in this post aren't numerous. Always a risk when pointing out others' typos.)

 

[Cheshire]

There are quite a few typos in the paper though. This may make it easier for the people who most need to hear its messages to dismiss it. (ie 'the sentence doesn't make sense, maybe the analysis was sloppy too')

It is odd as clearly a lot of time has been spent doing all the data gathering and analysis and the content is great; it just needed an hour of editing to finish it.

Hopefully there will be a more polished version of the paper later as it is one I would like to have in my armoury when dealing with doctors who are still stuck on the idea that behavioural and personality issues are the cause of ME/CFS.

(Fingers crossed my typos in this post aren't numerous. Always a risk when pointing out others' typos.)

From what I get, it's a pre-publication paper. The article has not yet been published. So the typos may be corrected. Let's hope it will be released soon, and then reach a wider audience.

 

[A.B.]

Beautiful article. Finally some sense and critical thought.

It's unfortunate that the article is based on just movement disorders and seizures.

And it could have been even more critical when it comes to the catastrophic consequences of labelling a health problem as psychogenic. In ME/CFS, they have been witholding help, research, treatment for decades now, in the belief that ME/CFS is merely a fashionable social construct for depressed somatisers that will go out of fashion if health practitioners avoid legitimising it.

 

[Snow Leopard]

Excellent paper!

 

[Jonathan Edwards]

A very nicely argued review. It will be good to see it as a formal publication. I doubt a few typos would detract from the clear writing style and they ought to get dealt with by a journal subeditor.

 

[A.B.]

Nevertheless, our conclusion is quite strikingly at odds with the literature in this domain, which expresses high levels of confidence in psychogenic accounts (e.g., Brown et al., 2011: “ Psychogenic nonepileptic seizures (PNES) ... have a psychological origin. ” ( p. 85). Gupta & Laing, 2006: “ Psychogenic movement disorders (PMDs) are movement disorders that result from a psychological or psychiatric rather than neurological disturbance ” (p. 430). There are a number of possible reasons for our very different conclusions. First, previous research has worked from the premise that these illnesses are indeed psychogenic in origin, and has not sought to scrutinize that premise.

And I suspect that if we search for the origin of this belief, we will find Freud, who was later shown to have fabricated the evidence to support his theories. It's all based on the lies of a quack.

 

[Kati]

Beautiful article. Finally some sense and critical thought.

It's unfortunate that the article is based on just movement disorders and seizures.

And it could have been even more critical when it comes to the catastrophic consequences of labelling a health problem as psychogenic. In ME/CFS, they have been witholding help, research, treatment for decades now, in the belief that ME/CFS is merely a fashionable social construct for depressed somatisers that will go out of fashion if health practitioners avoid legitimising it.

I have exchanged a few tweets with Carolyn and she says more is coming.

 

[chipmunk1]

Nice publication. We can only hope more of this type gets published.

Above, we discussed the possibility that a psychogenic diagnosis may impose an additional psychological burden on the patient

I would say the current bio-psycho-social model of somatization will effectively maximize biological, psychological and social damage done to an individual.

A further problem is that secondary gains are often evaluated without taking into account the associated losses, which may be wide and devastating (e.g., loss of financial and personal independence, loss of social contacts, leisure pursuits, and so on). Clearly, gains must significantly outweigh losses if they are to be motivating for the patient

Secondary gain is a huge pile of nonsense.

I think it is obvious who gains the most from such diagnoses.

This case illustrates how readily secondary gains can be found – even in severe organic illness - and the dangers of seeking them after a psychogenic diagnosis has been made

It's not just secondary gains that can be found in organic illness, almost any diagnostic criteria that they have used were found in organic neurological illness as well. (e.g response to suggestion, worsening with emotional stress, rapidly fluctuating symptoms, apathy towards symptoms, exaggerated concern with illness etc.)

Basically most diagnostic criteria they used turned be invalid but many are still using them.

Again, we need to be very certain our treatments are effective before we jump to such conclusions.

It's been over 100 years and there are still very few long term follow-up studies in the medical literature! I wonder why?

Many types of conversion disorder have not more than a handful of case studies in the entire medical literature despite being known for known for a long time. You don't even have to look for studies done with a small group of people. They often don't exist.

.Studies using artificial patient vignettes suggest that a patient’s complaints may be rated as less serious if they are believed to be psychogenic, and the patient is more likely to be characterised negatively

That would still be a good outcome. Seriously disabled individuals may end up homeless and denied any financial support or medical treatment. Some could be driven into suicide after being stigmatised and isolated from friends and family. The rate of misdiagnosis should be expected to be significant and the outcome in such a case could be devastating.

 

[chipmunk1]

And I suspect that if search for the origin of this belief, we will find Freud, who was later shown to have fabricated the evidence to support his theories. It's all based on the lies of a quack.

I would say it's based on cocaine binges. In this book from 1983 it is suggested that Freud's discoveries would coincide with the resumption of his cocaine consumption.

https://en.wikipedia.org/wiki/The_Freudian_Fallacy

It was not well received by medical scholars and the author had even been ridiculed for her theories.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1439796/?page=1

10 years later the field had mostly abandoned freudian philosophy. It continues it to be used to explain conversion disorders even when Freud's name is often not mentioned directly.

 

[PeterPositive]

Thanks for posting this!.

She wrote a new paper (which I haven't read, but I am sure it is good) 40 pages long, available here:

http://www.researchgate.net/publica...physical_illness_Time_to_examine_the_evidence

The article itself is only 17 pages long, the 40 pages total is when you include the massive list of references.

Just wanted to mention in case folks are scared by the hefty article.

It's well worth reading.

 

[chipmunk1]

Most importantly, psychogenic explanations also have serious practical consequences.Many experts advocate the minimization of disability aids in such cases, since they may reinforce false illness beliefs or provide secondary gains (Davison, Sharpe, Wade & Bass, 1999). Such denial of support would be a catastrophic error if the person’s disability were in fact intractable. A psychogenic explanation may also impact on the patient’s future medicalcare.

It's interesting that "psychogenic" means no disability aids. Would it be acceptable to deny sufferers of severe depression disability aids because it is a "psychological" disease? You really get to wonder what this is all about.

Our conclusion is not entirely at odds with historical precedent. In medicine, there is an ever-lengthening list of physical illnesses formerly attributed to psychological causes that are now associated with a biological disease process. These include: gastric ulcers (see e.g., Alp & Grant, 1970); multiple sclerosis (Caplan & Nadelson, 1980; Langworthy, 1948); ulcerative colitis (McKegney, Gordon, & Levine, 1970); rheumatoid arthritis (Moos, 1964); systemic lupus erythematosus (McClary, Meyer & Weitzman, 1955); and most recently, post-concussive syndrome (King, 2003vs.Gosselin et al., 2011; Shenton et al., 20)

She does not mention Diabetes, Cancer, AIDS, Asthma, Graves Disease, Dystonia ....

Nevertheless, our conclusion is quite strikingly at odds with the literature in this domain,which expresses high levels of confidence in psychogenic accounts.

 

[PeterPositive]

It's interesting that "psychogenic" means no disability aids. Would it be acceptable to deny sufferers of severe depression disability aids because it is a "psychological" disease? You really get to wonder what this is all about.

Good point, I've wondered about this issue many times.

There is a monumental difference between something "psychological" and something faked, on purpose. Our psychology is not necessarily under our direct control. We don't "decide" our psychological traits, or how we can or cannot cope with psychological trauma etc...

On the other hand fakers are just making symptoms up.

Why someone with an alleged psychogenic disorder is to blame more than - say - someone with a disabling liver cirrhosis caused by a bad life style? ( and isn't life style psychogenic too?! )

 

[ScottTriGuy]

@Kati

Thanks Kati - excellent info for our side.

 

[Aurator]

It is very good.


There are quite a few typos in the paper though. This may make it easier for the people who most need to hear its messages to dismiss it. (ie 'the sentence doesn't make sense, maybe the analysis was sloppy too')

It is odd as clearly a lot of time has been spent doing all the data gathering and analysis and the content is great; it just needed an hour of editing to finish it.

Hopefully there will be a more polished version of the paper later as it is one I would like to have in my armoury when dealing with doctors who are still stuck on the idea that behavioural and personality issues are the cause of ME/CFS.

(Fingers crossed my typos in this post aren't numerous. Always a risk when pointing out others' typos.)

I've read about half of it and found only one typo: a capital where there should have been a lowercase letter. Can you tell us some others you've found?