(not important) 2014 Wessely book's chapter on Somatization.

[Hip]

I don't think it is just Wessely who is writing this stuff, other adherents of somatization disorder are also pumping out similar nonsense. Wessely is the name we all know, but many other psychiatrists and professors are peddling such somatization garbage as well.

For example, the somatic symptom disorder DSM-5 working group, whose purpose it was to update the definition somatization disorder (it was redefined as somatic symptom disorder) for the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), comprised the following members:

Members of the somatic symptom disorder DSM-5 working group:

Joel Edward Dimsdale. Emeritus Professor of Psychiatry, University of California, San Diego, USA.

Arthur Joseph Barsky. Professor of Psychiatry at Harvard Medical School and the Director of Psychiatric Research in the Department of Psychiatry at the Brigham and Women’s Hospital in Boston, Massachusetts, USA.

Francis Creed. Professor of Psychological Medicine, University of Manchester, UK

Michael Ray Irwin. Professor, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles, USA.

Francis Keefe. Professor in the Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, USA.

Sing Lee. Chair of the Classification, Diagnostic Assessment and Nomenclature Section of the World Psychiatric Association.

James Lloyd Levenson. Professor of Psychiatry, Medicine, and Surgery at the Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA.

Michael Sharpe. Chair in Psychological Medicine at the University of Edinburgh, UK.

Lawson Reed Wulsin. Professor of Psychiatry and Family Medicine at the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.

Presumably many of these guys above must be writing books on somatization disorder / somatic symptom disorder.

 

[chipmunk1]

doesn't that violate the code of medical ethics? Not telling a patient the true diagnosis? Is this even legal in these days?

Pychiatry seems to live in another dimension.

You would think that a patient has the right to know what's wrong with them even if they believe it might worsen the course of the illness. Even if somatization disorders would really exist a patient always has the right to know.

at least that is what you would think!

 

[Valentijn]

doesn't that violate the code of medical ethics? Not telling a patient the true diagnosis? Is this even legal in these days?

In one of his (published?) musings, Wessely admitted that ethics was not part of the curriculum when he was a student. So he just makes it up as he goes along.

Much like his research, come to think of it.

 

[Countrygirl]

doesn't that violate the code of medical ethics? Not telling a patient the true diagnosis? Is this even legal in these days?

Pychiatry seems to live in another dimension.

You would think that a patient has the right to know what's wrong with them even if they believe it might worsen the course of the illness. Even if somatization disorders would really exist a patient always has the right to know.

at least that is what you would think!

Good point! Can anyone with relevant knowledge answer this question? I for one would really like to know.

It may seem extraordinary, but what appears to be obviously contrary to common sense to sane mortals is actually not illegal. For example: when I raised the refusal of local GPs to accept the existence of ME, which actually led to the death of a local vicar, with the relevant county authority they told me that doctors have the prerogative of deciding whether or not a disease/condition/illness existed based solely on their own opinion/prejudice and they can treat a patient accordingly. This sounded ridiculous, but it is apparently true. If this is so, although common sense and decency dictates that a patient has the right to know how a doctor views the nature of their illness, maybe the doctor is deemed to have the prerogative of deceiving the patient................for his good , of course. (This seems to be becoming my favourite emoticon of late.............must be becoming increasingly cynical in my old age...............or is it mere experience?)

 

[SDSue]

This text could have been written 100 years ago and that is my main problem with psychiatry. There is NEVER any progress or new ideas; just more vehement assertions and entrenchment of old ideas. As new evidence comes in challenging the somatisation status quo, it is always dismissed as some mendacious money grubbing doctor - crazy patient collusion. The bar for proof of organic illness is set so high - evidence must be absolutely unassailable - that almost nothing can ever satisfy it, and when something does satisfy it occasionally, like MRI and multiple sclerosis lesions or H. pylori and stomach ulcers, it's just quietly dropped from the new editions of such textbooks and never mentioned again, never taught to psychiatry trainees as historical examples of misguided treatment and abuse of patients, nothing.

Someday soon, ME/CFS will also drop from the Somatization chapters but I believe this will be different. We won't go quietly. Our numbers are vast, we have been abused for a long long time, and with the internet we have the ability to be very vocal and united. (Of course, that will depend upon whether we still care once we're healed and running amok!)

Perhaps since their attitudes and beliefs are so archaic, it would be appropriate to bring back the stocks for some long overdue public humiliation! hehe

 

[Valentijn]

Perhaps since their attitudes and beliefs are so archaic, it would be appropriate to bring back the stocks for some long overdue public humiliation! hehe

A nice fantasy But more realistically, I expect that there will be wide-spread calls for their dismissal from clinics and universities, and large-scale retractions of the published papers making groundless and inflated claims.

 

[chipmunk1]

Good point! Can anyone with relevant knowledge answer this question? I for one would really like to know.

It may seem extraordinary, but what appears to be obviously contrary to common sense to sane mortals is actually not illegal. For example: when I raised the refusal of local GPs to accept the existence of ME, which actually led to the death of a local vicar, with the relevant county authority they told me that doctors have the prerogative of deciding whether or not a disease/condition/illness existed based solely on their own opinion/prejudice and they can treat a patient accordingly. This sounded ridiculous, but it is apparently true. If this is so, although common sense and decency dictates that a patient has the right to know how a doctor views the nature of their illness, maybe the doctor is deemed to have the prerogative of deceiving the patient................for his good , of course. (This seems to be becoming my favourite emoticon of late.............must be becoming increasingly cynical in my old age...............or is it mere experience?)

well if this is still acceptable this would need to be changed to reflect modern standards.

A doctor is a service provider a patient can consult. You are not the property or pet of the doctor neither is he your caretaker in most cases. It is not too much to expect him to be truthful in all interactions.

Even consumer protection laws would cover that i guess. Could you image buying a car and being intentionally deceived because the (well intentioned) salesman believes that you would be better off with another type of car but would not accept that?

Witholding crucial information from a patient to influence the decision making is not ethical.

 

[chipmunk1]

If the patient has a specific illness belief ('candida, 'ME', 'chronic allergy'), do not question this, even if there is no corroborating evidence.

this is from a profession that has not one single lab test, biomarker or brain scan that can show the proper diagnosis has been made.

 

[SDSue]

this is from a profession that has not one single lab test, biomarker or brain scan that can show the proper diagnosis has been made.

 

[Aurator]

I would love to know how Simon Wessely would respond to such an answer from a patient...We are not talking about feeling a bit stiff or tired a day after exercise - hey we are all familiar with such feelings when healthy, or even recovering from earlier illnesses, but something rather more distinctive.

He would not feel challenged by it in the least, I'd imagine. The essence of his answer would be that you had engaged in a self-fulfilling prophecy by "catastrophizing" in respect of the activities that preceded the PEM; that the PEM you report is entirely a product of that catastrophization, and the more extreme you report your physical symptoms to be, the more extreme has been that catastrophization.

His assertion would of course be uninvalidatable in precisely the same proportion as it is unverifiable.

The secret is not to take seriously any people who make a career out of peddling these sorts of contemptible fallacies, and, more importantly for PWME, not to go anywhere near them.

 

[SilverbladeTE]

They get away with it because the UK's "system" is Victorian and actually Medieval in parts, in outlook and attitudes.
It is also grossly arrogant, racist, perverse etc
You are either one of "the elite", or you are a subhuman.
They try to deny this, but that crap is still endemic to the "professional" and (upper) middle classes.

If you do not fit in THEIR wold view, then they alter the facts to fit their world view.

 

[chipmunk1]

it's even worse:

Pharmacological management

Depression and anxiety are often present and need treatment. There is
some evidence that low-dose tricyclics can be effective where pain and
sleep problems coexist. Many patients are reluctant to take
antidepressants, but may accept them on these grounds.

They seem to suggest not to tell patients about the true reason why they should take antidepressant drugs.

they don't tell them you are depressed you should take some antidepressant medication.

They tell them take this medicine it is for your sleep and pain problems.

 

[alex3619]

I see no such explanation, only the assertion that such a phenomenon exists. Probably because it has as much scientific validity as the concept of demonic possession.

This is recycled discredited Freudian nonscience. Psychiatry has nobody to blame but itself when it loses credibility over such claims. Psychiatrists need to clean up their own profession. The problem is,I think, that if they dot rid of everything dubious or outright speculative there would be not very much left.

 

[alex3619]

well if this is still acceptable this would need to be changed to reflect modern standards.

People have been writing and complaining about this since the 19th century, including Popper (I think, by inference) and Szatz(its one of his main claims). The medical profession has the legal right in most if not all countries to make unfounded unscientific diagnoses and treat people accordingly. The biggest examples of quackery in medicine are within the profession itself. It has legal protections. Trying to sue one of them is very hard to do.

 

[eafw]

they don't tell them you are depressed you should take some antidepressant medication.

They tell them take this medicine it is for your sleep and pain problems.

Yes, this is widely known amongst patients at UK CFS clinics, and the pyschs while lying to our faces will happily discuss it behind our backs - there are published papers on the subject along with books like the one in this thread.

It's quite bizarre, the hiding in plain sight almost. A sign of people who believe themselves to be basically untouchable.

If anyone can get hold of the full paper, I think they talk about the conning people onto antidepressants here

http://www.ncbi.nlm.nih.gov/pubmed/11144910

 

[zzz]

doesn't that violate the code of medical ethics? Not telling a patient the true diagnosis?

I did a bit of research into medical ethics last year when I was dismayed at the way I was being treated by my doctor. To my surprise, I found that medical ethics is actually a beautiful system that puts the patient's interests foremost, and has many protections in place to assure that they patient gets the best care.

In general, medical ethics is described in terms of the four ethical principles of autonomy, beneficence, nonmaleficence, and justice. These are discussed in many, many sources. Interpretation of them is not always the same, however, and some schools of thought (and many physicians) believe that there are numerous exceptions that can be made for the greater good of the patient (in their eyes). These exceptions tend to weaken the whole foundation of medical ethics, moving it toward a "whatever the doctor thinks is best" point of view, which allows virtually anything.

One of the most useful summaries of medical ethics I have found is an a chapter called The Language of Bioethics, in a Continuing Education for Health Professionals. Here are some relevant excerpts; those who are interested in more detail may wish to read the entire page, or do a Google search for "medical ethics autonomy beneficence nonmaleficence justice", which will bring up many articles on this topic.

From The Principle of Autonomy:

Respect for autonomy requires that patients be told the truth about their condition and informed about the risk and benefits of treatment. Under the law, they are permitted to refuse treatment even if the best and most reliable information indicates that treatment would be beneficial, unless their action may have a negative impact on the well-being of another individual. These conflicts set the stage for ethical dilemmas.

The concept of autonomy has evolved from paternalistic physicians who held ethical decision-making authority, to patients empowered to participate in making decisions about their own care, to patients heavily armed with Internet resources who seek to prevail in any decision-making. This transition of authority has been slower to evolve in the geriatric population but, as the baby boomers age they will assert this evolving standard of independence. Autonomy, however, does not negate responsibility. Healthcare is at its foundation a partnership between the provider and the recipient of care. Each owes the other responsibility and respect (Veatch, 2003).

From The Principle of Beneficence:

The beneficent practitioner provides care that is in the best interest of the patient. Beneficence is the act of being kind. The actions of the healthcare provider are designed to bring about a positive good. Beneficence always raises the question of subjective and objective determinations of benefit versus harm. A beneficent decision can only be objective if the same decision was made regardless of who was making it.

Traditionally the ethical decision making process and the ultimate decision were the purview of the physician. This is no longer the case; the patient and other healthcare providers, according to their specific expertise, are central to the decision-making process (Valente, 2000). For example, physical and occupational therapists have expertise in quality-of-life issues, and in this capacity can offer much to the discussions of lifestyle and life-challenging choices, particularly when dealing with terminal diseases and end-of-life dilemmas.

From The Principle of Nonmaleficence:

Nonmaleficence means doing no harm. Providers must ask themselves whether their actions may harm the patient either by omission or commission. The guiding principle of primum non nocere, “first of all, do no harm,” is based in the Hippocratic Oath. Actions or practices of a healthcare provider are “right” as long as they are in the interest of the patient and avoid negative consequences.

From The Principle of Justice:

Justice speaks to equity and fairness in treatment. Hippocrates related ethical principles to the individual relationship between the physician and the patient. Ethical theory today must extend beyond individuals to the institutional and societal realms (Gabard and Martin, 2003).

Justice may be seen as having two types: distributive and comparative. Distributive justice addresses the degree to which healthcare services are distributed equitably throughout society. Within the logic of distributive justice, we should treat similar cases similarly, but how can we determine if cases are indeed similar? Beauchamp and Childress (2001) identify six material principles that must be considered, while recognizing that there is little likelihood all six principles could be satisfied at the same time.

Principles of Justice​

To each person an equal share
To each person according to need
To each person according to effort
To each person according to contribution
To each person according to merit
To each person according to free market exchanges

Comparative justice determines how healthcare is delivered at the individual level. It looks at disparate treatment of patients on the basis of age, disability, gender, race, ethnicity, and religion. Of particular interest currently are the disparities that occur because of age.

And then there is the Principle of Veracity, which is usually subsumed under the Principle of Autonomy:

Veracity (truthfulness) is not a foundational bioethical principle and is granted just a passing mention in most ethics texts. It is at its core an element of respect for persons (Gabard, 2003). Veracity is antithetical to the concept of medical paternalism, which assumes patients need to know only what their physicians choose to reveal. Obviously there has been a dramatic change in attitudes toward veracity because it forms the basis for the autonomy expected by patients today. Informed consent, for example, is the ability to exercise autonomy with knowledge.

Decisions about withholding information involve a conflict between veracity and deception. There are times when the legal system and professional ethics agree that deception is legitimate and legal. Therapeutic privilege is invoked when the healthcare team makes the decision to withhold information believed to be detrimental to the patient. Such privilege is by its nature subject to challenge.

Is [not telling a patient the true diagnosis] even legal in these days?

Unfortunately, yes. Medical ethics are just that - ethical guidelines. They generally do not have the force of law.

 

[IreneF]

I wonder how psychiatrists respond to patients who have ME or CFS symptoms but no evidence of somatization? E. g. the illness is new, the person doesn't go to the doctor very often, and has no evidence of anxiety or depression? Do they just assume that it's somatization, even if none of the criteria are met?

 

[zzz]

I wonder how psychiatrists respond to patients who have ME or CFS symptoms but no evidence of somatization? E. g. the illness is new, the person doesn't go to the doctor very often, and has no evidence of anxiety or depression? Do they just assume that it's somatization, even if none of the criteria are met?

Please see The Rosenhan Study: On Being Sane in Insane Places. (Or you can see a summary here.) This is a famous experiment in psychiatry. Eight pseudopatients - sane people - gained admission to 12 mental hospitals in five states. The method of obtaining admission is described in the article:

After calling the hospital for an appointment, the pseudopatient arrived at the admissions office complaining that he had been hearing voices. Asked what the voices said, he replied that they were often unclear, but as far as he could tell they said "empty," "hollow," and "thud." The voices were unfamiliar and were of the same sex as the pseudopatient. The choice of these symptoms was occasioned by their apparent similarity to existential symptoms. Such symptoms are alleged to arise from painful concerns about the perceived meaninglessness of one's life. It is as if the hallucinating person were saying, "My life is empty and hollow." The choice of these symptoms was also determined by the absence of a single report of existential psychoses in the literature.

Beyond alleging the symptoms and falsifying name, vocation, and employment, no further alterations of person, history, or circumstances were made. The significant events of the pseudopatient's life history were presented as they had actually occurred. Relationships with parents and siblings, with spouse and children, with people at work and in school, consistent with the aforementioned exceptions, were described as they were or had been. Frustrations and upsets were described along with joys and satisfactions. These facts are important to remember. If anything, they strongly biased the subsequent results in favor of detecting insanity, since none of their histories or current behaviors were seriously pathological in any way.

Immediately upon admission to the psychiatric ward, the pseudopatient ceased simulating any symptoms of abnormality.

How long do you think it took them to get discharged? Much longer than they expected, it turns out. Being and acting completely sane is not enough to convince a psychiatrist that you are sane. All pseudopatients were forced to admit to having a mental illness and agree to take antipsychotic drugs as a condition of their release.

However, unlike the psychiatrists, many other patients could tell that these were sane people:

Finally, it cannot be said that the failure to recognize the pseudopatients' sanity was due to the fact that they were not behaving sanely. While there was clearly some tension present in all of them, their daily visitors could detect no serious behavioral consequences -- nor, indeed, could other patients. It was quite common for the patients to "detect" the pseudopatient's sanity. During the first three hospitalizations, when accurate counts were kept, 35 of a total of 118 patients on the admissions ward voiced their suspicions, some vigorously. "You're not crazy. You're a journalist, or a professor (referring to the continual note-taking). You're checking up on the hospital." While most of the patients were reassured by the pseudopatient's insistence that he had been sick before he came in but was fine now, some continued to believe that the pseudopatient was sane throughout his hospitalization [11]. The fact that the patients often recognized normality when staff did not raises important questions.

Rosenhan then performed another experiment:

For this experiment, Rosenhan used a well-known research and teaching hospital, whose staff had heard of the results of the initial study but claimed that similar errors could not be made at their institution. Rosenhan arranged with them that during a three-month period, one or more pseudopatients would attempt to gain admission and the staff would rate every incoming patient as to the likelihood they were an impostor. Out of 193 patients, 41 were considered to be impostors and a further 42 were considered suspect. In reality, Rosenhan had sent no pseudopatients and all patients suspected as impostors by the hospital staff were ordinary patients. This led to a conclusion that "any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one".

There was also a significant reduction in the number of admissions to the hospital suggesting that psychiatrists had been overadmitting before the non experiment was conducted.

Here are a couple of other related experiments:

In 1968 Maurice K. Temerlin split 25 psychiatrists into two groups and had them listen to an actor portraying a character of normal mental health. One group was told that the actor "was a very interesting man because he looked neurotic, but actually was quite psychotic" while the other was told nothing. Sixty percent of the former group diagnosed psychoses, most often schizophrenia, while none of the control group did so.[10]

In 1988, Loring and Powell gave 290 psychiatrists a transcript of a patient interview and told half of them that the patient was black and the other half white; they concluded of the results that "clinicians appear to ascribe violence, suspiciousness, and dangerousness to black clients even though the case studies are the same as the case studies for the white clients".[11]

In 2008, the BBC's Horizon science program performed a somewhat related experiment over two episodes entitled "How Mad Are You?". The experiment involved ten subjects, five living with previously-diagnosed mental health conditions, and five with no such diagnosis. They were observed by three experts in mental health diagnoses and their challenge was to identify the five with mental health problems solely from their behaviour, without speaking to the subjects or learning anything of their histories.[13] The experts correctly diagnosed two of the ten patients, misdiagnosed one patient, and incorrectly identified two healthy patients as having mental health problems. Unlike the other experiments listed here, however, the aim of this experiment was not to criticise the diagnostic process, but to minimise stigma of the mentally ill. It aimed to illustrate that people with a previous diagnosis of a mental illness could live normal lives with their health problems not obvious to observers from their behaviour. [14]

Notice that all but the last of these experiments were done decades ago. Yet the process of mental illness diagnosis has not changed significantly in the interim, and the diagnoses by mental health professionals are generally assumed to be correct and scientifically based, despite much evidence to the contrary.

 

[barbc56]

@zzz
Thanks for taking the time to post these studies. They are certainty eye opening.

In defense of the psychiatrists, they legally have to err on the side of caution in these type of situations. When a patient is seen with these symptoms, doctors don't have the time to make an in depth evaluation so the patient is referred to where these services are available.

Presently, at least in the US, it's not that easy to be placed in a psychiatric ward. Fifteen years ago it was just the opposite. One factor which has impacted delivery of mental health services is whether insurance will cover the cost of a patient's hospitalization. Litigation concerns are high in the US. What an unfortunate statement that makes.

There are also other factors such as services that weren't in place when some of these studies were done where there were basically two options, hospitalization or outpatient services. Nowdays there are other intermediate services such as day treatment facilities, home/phone monitoring between doctor visits. There's also the impact as far as a psychiatrist's role shifting more towards medication management and not therapy. Not saying these options are better but they are different across time.

While the above studies are interesting and make a very valid point how sanity can be in the eye of the beholder, unfortunately, the same limitations inherent in social science studies remain.

I'm not sure if these studies really give us that they give us that much information nor can be used as a generalized indictment against the psychiatric community. But definitely worth a read and food for thought as to what constitutes the definition of "sanity" in a culture which is a fascinating area of study.

Not that there isn't room for criticism.

Barb
ETA
I missed your post on ethics in medicine. Quite interesting.

 

[Gingergrrl]

Presently, at least in the US, it's not that easy to be placed in a psychiatric ward. Fifteen years ago it was just the opposite.

@Barb56 This is very, very true. There are very few psychiatric beds available and most insurance companies will deny admission. I worked in an outpatient program and even when we had patients who were acutely suicidal or floridly psychotic and gravely disabled AND these patients begged to be admitted voluntarily to the inpatient unit for help, we were often denied admission by insurance or there was no bed available. It seems to be the opposite of what is going on in the UK, I just don't know why!