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Simon Wessely and "all in the mind"

Discussion in 'General ME/CFS News' started by Esther12, Jan 3, 2012.

  1. Esther12

    Esther12 Senior Member

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    I thought I'd pull out a few recent quotes from Wessely about the absurdity of believing anyone would promote the view that CFS was 'all in the mind' - (what a straw-man!), and place the quotes from his 1997 discussion with Shorter afterwards, in which they themselves use the term unironically.

    Strangely, Wessely doesn't condemn Shorter's absurd quackery, but instead, seems more concerned of the dangers of speaking openly about accepting it. Shorter is a historian, but is heavily involved in the CFS quackfest. He wrote the opening chapter for Peter White's book on biopsychosocial medicine, which included another discussion with Wessely and others. When you read Wessely's earlier stuff on the danger of ME support groups etc, it clearly fits very well with Shorter's view of CFS as a manifestation of social hysteria, even if Wessely doesn't use the H word.

    http://www.spectator.co.uk/essays/all/7190703/mind-the-gap.thtml

    http://jnnp.bmj.com/content/83/1/4.full

    1997:


    http://forums.phoenixrising.me/showthread.php?14523-1997-Wessely-thing-(minor-more-morality-and-philosophy-than-CFS)

    Anyway... there are so many better reasons for criticising Wessely than that. It's pretty irritating that so much of the coverage around the anger patients feel towards Wessely simply parrots his own misleading claims on these matters though. It is possible to think that patients diagnosed with CFS have been poorly treated as a result of the work of Wessely and his colleagues, even if one does not despise all psychiatrists, think that mental health problems are not 'real' or fails to understand how mind and body can interact. If patients were all being lumped together and treated as if they were suffering from a retrovirus despite a lack of positive evidence that this is the case, that would be immoral quackery too.
  2. sianrecovery

    sianrecovery Senior Member

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    It is the fixed paucity of their thought that I find so wearing -and given the dynamic nature of the the changes in the human environment, bizzare - presumably when the Romans were slowly poisoning themselves with their marvellous lead pipes those suffering from lead poisoning had some learned git in a toga telling them to straighten themselves out. I think maybe the tide is turning tho', I bloody hope so anyway. As an ME sufferer in the UK, I cant really just laugh with contempt at these intellectually stunted and deeply incurious individuals because of the systemic harm they have done. Still, what goes around comes around, one way or another.
    Shell, leela, Francelle and 2 others like this.
  3. Enid

    Enid Senior Member

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    Well said sianrecovery - what mumbo jumbo still with us in the 21st century. Whilst they are trying to resolve their own difficulties I suggest they look into the more complicated areas in medicine - immunology, virology, neurology (and findings) - lots of good information/education there.
  4. Wildcat

    Wildcat Senior Member

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    Having read quantities of Professor Wesselys writing over a number of years, I have reached the conclusion that what he primarily does is not science, not medicine; what Prof Wessely mainly does is narrative devices, ie language games. An example of that here from his evidence to the Lloyd Inquiry in 2004 - a Public Inquiry into Gulf War Illness:



    Evidence to the Public Inquiry into Gulf War Illnesses by Professor Simon Wessely:



    http://www.lloyd-gwii.com/hearing.asp

    INDEPENDENT PUBLIC INQUIRY INTO GULF WAR ILLNESSES


    MINUTES OF PROCEEDINGS

    Held at

    1 The Abbey Garden, London, SW1P 3SE

    on

    Tuesday 10 August 2004

    DAY EIGHT



    Lord Lloyd of Berwick, in the Chair
    Dr Norman Jones
    Sir Michael Davies




    THE CHAIRMAN: 'How did you first become interested in the question of the Gulf War illnesses?'


    A. [Professor Wessely]: 'Well, I do not know if it is helpful to take you through what it was suggested that I do which would answer that particular question. What I was going to do was start from when we became interested in this subject, which was ten years ago now. I am going to follow the old nursery rhyme of old, new, borrowed and blue to try and tease out the various threads of this problem and emphasise that what we are dealing with here is a very complex issue with no single cause. That is a little mnemonic I use sometimes.'.....

    .
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  5. Enid

    Enid Senior Member

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    Do you think more study of the advances/findings in current research - immunology, neurology and virology (for ME) might aid him. After all lots of new research and findings and understanding he never seems to mention.
    justinreilly likes this.
  6. Wildcat

    Wildcat Senior Member

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    Enid wrote: "Do you think more study of the advances/findings in current research - immunology, neurology and virology (for ME) might aid him. After all lots of new research and findings and understanding he never seems to mention."



    No, Enid, I don't think that would help him. I strongly suspect that Prof Wessely has his own agenda and does not want to be 'helped' in that way.

    .
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  7. Esther12

    Esther12 Senior Member

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    He does sometimes act as if he's in a Neil Gaiman novel....

    The evasive way he talks about the reasons why so many patients hate him really piss me off.

    Here are my top reasons (broad reasons, rather than specific papers, or points):

    1) His work helped create the social setting which led to two decades (and this is still ongoing, even after Wessely has abandoned the idea) of doctors telling patients with chronic fatigue that they are really 'just' depressed, but are refusing to admit it. Wessely's work played a couple of different roles in legitimising this quackery: i) over-emphasising the role of depression in CFS (which he seems to have now accepted was a mistake, although has not apologised for it) and more importantly ii) promoting the view that it is acceptable for those operating in a position of authority to lump together those suffering from physical symptoms, and make assumptions about their mental health that are not supported by the identification of cognitive distortions or the patient's own view of their emotional state.

    2) His promotion of a pragmatic approach towards the cognitions of patients diagnosed with CFS. People's cognitions should be understood as part of their pursuit of truth, and not assessed in functional terms, otherwise massive power is placed in the hands of those who claim to be able to measure the outcomes of different cognitions. Maybe those patients who are encouraged to believe that CFS is the result of deconditioning end up being marginally less disabled... to promote such an idea would still be quackery unless you had compelling evidence that CFS was the result of deconditioning (and the evidence we now have seem to indicate quite strongly that this is not the case).

    3) His lazy use of RCT's to pragmatically justify psychosocial interventions. The promotion of the notion that CFS is (for example) the result of deconditioning leads to social costs for patients which will not be captured in an RCT (unless they are actively controlled for, and I have never seen this done). Most of the harm done by the psychosocial approach to CFS that has affected my partner and I has occurred through social mediums. Without accounting for these, psychosocial treatments cannot be justified on pragmatic grounds.

    4) His tolerance for dishonest paternalism, which leaves patients unable to trust their doctors. If someone tries to defend paternalism by saying (as Wessely did) "I am paternalistic towards my children, which doesn't mean that I don't love them", then that shows that they really do not understand what the problem with paternalism is.

    5) The expansion of the medical purview to include psychosocial factors, without there being any equivalent increase in the regulation and accountability of the medical profession. He seems to have a rather broad faith in medical practitioners and their ability to act fairly and reasonably with regards to their patients, combined with a belief that patients can be thrown badly off course by all manner of different subconscious distortions and influences, is pretty irritating.

    6) The way all of the above combine: The corruption of the 'scientific' process with paternalistic, pragmatic social concerns about the narrative being constructed by researchers. Were the PACE results spun because the researchers wanted to keep earning money from providing worthless treatments, or because they thought a misleading presentation of their results would encourage more positive cognitions amongst patients? I don't know, but I don't think it's a coincidence that CFS is at the forefront of pragmatic paternalism, and quackery. When patients are stripped of the right to be spoken to honestly and clearly on the assumption that they can decide for themselves how they want to live their lives, then we should not be surprised when those placed in positions of authority over them come to abuse their power, and patients respond with anger and hatred.

    Some discussion of spin around PACE here: http://forums.phoenixrising.me/inde...d-releasing-data-on-recovery-from-pace.20243/

    I've already got three more to type out, and more keep occurring as I type (I wanted three brief points as examples)... but I'm getting tired, and boring myself. Wessely's pretence that there is no reason for hating him other than his association with psychiatry is pretty irritating. He must know that it is not true, even if he still believes that, overall, he has done more good than harm.

    edit: It feels rather cheap to just list reasons why I hate the man on a website where I know no-one will try to defend him.... but I'm not going to delete it all after having bothered to type it out! It would be good to have some Wessely defenders here, or a website forum for doctors of psychosocial medicine.
    Snow Leopard likes this.
  8. alex3619

    alex3619 Senior Member

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    Hi Wildcat, its more than just language games. He and those who think like him use it as a weapon even regarding formal studies. In the PACE trials CFS is not CFS, ME is not ME, pacing is not pacing, "normal" is not normal. Everything has a twisted, different definition. Yet this is never explained to the media. If someone challenges, they can always point back to the paper and say it was misunderstood. As this is practiced, taking into account the media interviews, it looks very much like a deliberate campaign of misdirection and deception. If they were to spell out the definitions then it would be just a methodological difference, but they don't do this. Now they might claim this is a failure of the media, but its too systemic, too frequent. Therefore its most probably a ploy to make their research sound more important than it is.

    Language is what they play with. They use language to reprogram, ahhh ... re-educate people about things. Soviet Russia did something similar, including reclassifying dissidents as crazy, a comparison that was made by Hooper some years ago.

    Bye
    Alex
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  9. jonnyboy

    jonnyboy

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    I think Wessely missed his calling, he could have been a politian based on how he avoids answering the question, and the way in which he mixes words.
    pollycbr125 likes this.
  10. justinreilly

    justinreilly Stop the IoM & P2P! Adopt CCC!

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    Understatement of the millenium!
  11. justinreilly

    justinreilly Stop the IoM & P2P! Adopt CCC!

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    Right! and/however I actually think he would much prefer being a doctor than a politician since if he were a politician people would examine his actions, see thru his BS in a second and put him out of office. Instead being a doctor/professor is good for him since noone will question him since he's supposedly a 'scientist' and a doctor so 'why would he be abusing patients?' So, like the serial murdering doctors thru history he can keep killing people for decades without being caught.
    pollycbr125 and Francelle like this.
  12. justinreilly

    justinreilly Stop the IoM & P2P! Adopt CCC!

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    Exactly! especially: "In the PACE trials CFS is not CFS, ME is not ME, pacing is not pacing, "normal" is not normal. Everything has a twisted, different definition. Yet this is never explained to the media."
  13. justinreilly

    justinreilly Stop the IoM & P2P! Adopt CCC!

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    I think it would be great for informed patients like us to talk to doctors on their blogs, internet forums, facebook, yahoo groups etc. in a logical way as you are doing here! Maybe you or someone else could do this. I am going to start trying to talk to psychiatrists and psychologists on the blogs, etc. that deal with DSM 5 in order to alert them to the problems with it for us.
  14. Wildcat

    Wildcat Senior Member

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    Hi Alex and Justin,


    Wildcat wrote "what Prof Wessely mainly does is narrative devices".


    Am too wiped out to discuss literary theory at present, but just a quickie.


    .

    Justin wrote: Exactly! especially: "In the PACE trials CFS is not CFS, ME is not ME, pacing is not pacing, "normal" is not normal. Everything has a twisted, different definition. Yet this is never explained to the media."


    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~




    Narrative Devices: Tools employed by the author or narrator which are used to better communicate the plot of a story to the audience.




    An embedded narrative is a "story within a story," contained within a framing narrative.

    Contained within a framing narrative, an embedded narrative hinges contextually on the framing narrative, while typically becoming the bulk of the story itself. In other words, the embedded narrative usually comprises the majority of the text, while the framing narrative occupies just the first and last few pages.
    http://narrative.georgetown.edu/wiki/index.php/Embedded_narrative
  15. Esther12

    Esther12 Senior Member

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    I've not had much luck. The best I get is "That does sound bad, but I'm afraid that it's not an area I know much about."

    The quackery around CFS is so complicated, that most people, understandably, are unwilling to put in the time and effort needed to understand our concerns about it. It's also really easy and safe to just maintain a deference for authority and claimed expertise - no-one has ever lost their job for trusting what the 'experts' told them.

    I've never found anyone on-line who was really willing to attempt to defend the psychosocial approach to CFS, other than in the most luke-warm manner... the true believers must keep quiet.
  16. Holmsey

    Holmsey Senior Member

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    When I first joined this forum I had rather a lot of fall outs doing just that, maybe even with you? Knowing little of the man, a fact many members found bewildering, I played devils advocate and tried to approach everything about him in an unbiased way, I was even mailing back and forward until I said some things which caused him to end the dialog.

    Now, having had time to develop an opinion of my own I think you are left with two options, that as many suggest he has an agenda we can only guess at while having little remorse for the damage he's caused both directly and indirectly. Alternately, that his ego was so great as to believe every scientific study suggesting he had it wrong was flawed and now, the truth having pushed its way in, he works to reposition all of his previous views in a frantic later day defence as if in preparation for a public trial.

    In either case Esther, what came through in your mail was not hate but sound reason and I applaud your control.

    Note: As I did, you only find out about Wessely when you start researching your illness, you won't hear a GP mention him, given that only a small number of the estimated 250,000 sufferers in the UK are members of forums like this then it's likely that 'most' sufferers don't research and have never heard of him.
  17. Esther12

    Esther12 Senior Member

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    I could be misremembering (in a way that is unfair on you), but I think I criticised some of your posts for expecting others to do your research for you instead of doing your own reading, rather than for being supportive of Wessely etc.

    At the time, I was less hostile of the psychosocial approach to CFS and those involved with promoting it (partly from being less well read, partly because the manner in which the results from the PACE trial have been spun make it harder than ever to give those involved the relentless benefit of the doubt they require, and partly from realising that they weren't just irrelevant quacks to be ignored but people whose work had had a profound impact upon the way I was treated and viewed by others), but tended to write in a more hostile way in conversations with others here - I was not used to forums which were intended to be 'supportive', and was more used to forums used for pretty adversarial debate. I could well have been unfairly aggressive in responding to you, particularly if you were taking a minority position here and already felt barracked - good to see that you have returned.

    When I see Wessely et al. being criticised unfairly, I still try to make the effort to defend them (through gritted teeth), but it would be good to have members who were well well read on the psychosocial approach to CFS and yet still keen supporters of it.

    I think that we can all try to spin our own histories in ways which help absolve us of responsibility for our mistakes. That Wessely has been so hated by patients, for so long, while maintaining the respect of many of his peers, would make it even harder for him to really acknowledge the problems that he has caused and the mistakes he has made. On a human level, I have some sympathy for him - although still hate him, obviously.

    Thanks. I slightly regret writing it, but it could certainly be worse.
  18. alex3619

    alex3619 Senior Member

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    The usual issue with someone pushing a challenged hypothesis is that they dig in and and try even harder to prove it. I do not discount the possibility that this is the case with the biopsychosocial adherents. That could be right. For maverick scientists whose hypotheses are finally accepted, we laud them as heroes. Those who fail to have their theories validated, despite all there efforts, are eventually forgotten except as cautionary tales.

    The problem is that the biopsychosocial school is having most of its impact through media and public service promotion, not scientific debate. The bulk of psychiatrists and researchers and other MDs have failed to engage the debate, and so the view has proliferated by default. The more reasoned and moderate bioscience view has produced successes that dwarf the biopsychosocial successes but they are engaged in scientific debate, not media and government promotion. So the message is quieter and harder to hear: most are completely unaware of the bioscience advances in ME in the last decade.

    Bye
    Alex

    I am considering (in the long term) writing a blog called The Dark Age of Medicine or something. I think that both evidence based medicine and psychosomatic theories need to be challenged, not just CBT/GET for ME.
    Snow Leopard and justinreilly like this.
  19. Esther12

    Esther12 Senior Member

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    Wessely has altered his beliefs in some ways, and produced papers with data that challenge his own ideas (even if they often have no effect on the view of CFS he promotes to the media). In his papers, he tends to avoid laying out his own ideas clearly, but just emphasises certain parts of the available evidence in the way which will tend to create a particular narrative for the reader - it means that it's often hard to say exactly and with certainty what it is that 'he' as an individual believes.

    I'm not sure how much I disagree with him about the (few) facts that surround CFS, but I certainly disagree with the morality of his approach to CFS. The same with White, who has done some decent work on the affects of glandular fever, that seem utterly incompatible with the manner in which he has promoted certain cognitive behavioural approaches to CFS. (White does also pimp this paper as evidence that individual's responses to GF are more important than the virus itself, when it really doesn't. I don't know what's motivating that: http://forums.phoenixrising.me/show...a-psycho-educational-intervention-to-aid-reco)
  20. Esther12

    Esther12 Senior Member

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    From Unum's 2007 CMO report

    It seems that this is now off-line, ungoogleable (?) and only availably on a web archive, so I thought I'd post it here. It's best understood within the context of the medical insurance industry and it's approach to CFS, and the other sections of the report (available at link below) are of some interest too, but it's not something I'd encourage everyone to read.

    http://web.archive.org/web/20081030...ome/AccessiblePDF/CMOReport2007.htm?UPCC=True

    Why and When do Doctors Collude with Patients? - Professor Simon Wessely - Director King's Centre for Military Health Research.

    Collusion it must be a bad thing, mustn't it? Just recently, Conrad Black was found guilty of colluding with some fellow directors to defraud his shareholders, some airlines were accused of colluding in price fixing, as was the USA of colluding with China to bypass global warming targets. But doctors, as members of a highly prestigious helping' profession, couldn't possibly do such a thing.

    But we do, and we do so every day. Sometimes we do so out of self-interest. But more often than not it is done from a genuine belief that it is in the interests of the patient. And sometimes it is even true.
    What The Patient Doesn't Know Won't Hurt.

    All medical students nowadays have drummed into them the concepts of autonomy and shared decision making. Paternalism is as outdated as using a stethoscope to take a blood pressure or an oral thermometer to take a temperature. I sometimes tell our students that I am paternalistic towards my children, which doesn't mean that I don't love them, but it falls on deaf ears. So now if you are sick and faced with some tricky choices, there's no point in asking your young doctor what you should do - the response will be "what do you think?" The temptation to respond with "you're the one who went to medical school, not me" cuts no ice anymore. Our modern doctor will give the options, and then ask the patient to decide.

    OK, so even an old cynic like me has to admit that this is progress. Most patients, most of the time, want to know the unvarnished truth. Thankfully the days when we withheld the diagnosis of cancer because we felt people couldn't cope have gone. And if it is bad news, so be it. A recent study showed that 87%of parents whose children had life threatening illness, namely cancer, desired as much information about the prognosis as possible. But the 13% who didn'twant to know were not even spared distress there was no association between distress and not wanting to know everything. So whatever else colluding withthe parents was doing, it wasn't sparing their distress (Mack et al 2006).

    But there remains a small minority of patients who genuinely do not want to know the bad news, at least not all of it and not right now. Faith, hope and charity all play a part (Leydon et al, 2000). Sometimes it is because the patient really does trust the expert, and doesn't want to know any more. Sometimes the patient wants to maintain hope, and avoiding distressing information can enable them to carry on with their lives for a while longer. And sometimes it is charity thinking that there really isn't enough time for the doctor to tell them everything, and to do so will only make things harder for the rest of the patients in the queue (Leydon et al, 2000). And it is nothing to do with intelligence, background or training. A former editor of the New England Journal of Medicine, himself an oncologist, admitted that when he was diagnosed with cancer he did not want to know everything, nor to take all the decisions himself.

    So gradually our ethically pure new doctors will learn just how in real life things are not neat and simple, but grey and ambiguous. As another study of cancer doctors and their patients showed - "The doctor did and did not want to pronounce a death sentence' and the patient did and did not want tohear it" (The et al 2000). Sometimes a little collusion can go a long way.
    Collusion and the Number Needed to Offend.

    So we collude out of a paternalistic belief that the patient's interests are not best served by sharing everything that we know. And sometimes we collude because we feel that any other course of action will lead to confrontation, and adversely affect not just our relationship with the patient, but the illness itself.

    Take the example of hysteria. Despite being so often described as on the decline it is instead - as the authors of one study put it with tongue, oneassumes, firmly in cheek -"alive and kicking". Slater's view that a diagnosis of hysteria merely reflected ignorance, and that most cases would turn out to have diagnosable disease if they were properly investigated or followed up for long enough, has been repeatedly disproved. Go to a neurology clinic and there will be a few patients unable to walk, or unable to see, and yet who quite clearly do not have any organic disease to account for this. Likewise, there existthose who have all the features of epilepsy but a normal Electro-encephalograph (EEG) even in the middle of what looks like a grand mal convulsion.

    So when the scans, EEGs and nerve conduction tests are back, and the diagnosis clear, what happens next? Does our ethically trained doctor, embracing autonomy and avoiding paternalism, share this information with the patient? "Sir/Madam there is no neurological reason why you cannot walk. You have what psychiatrists call conversion disorder, but everyone else calls hysteria". You can bet your bottom dollar that they do not. In another study nearly every UK neurologist admitted seeing patients for whom the diagnosis of hysteria and/or conversion disorder was appropriate, but hardly any used that label in front of the patient. Instead most took refuge in a variety of euphemisms.

    And who can blame them? In one of those papers that one wishes one had written oneself, Stone et al showed the importance of labels, and the hierarchyof euphemisms, devising a new metric - the Number Needed to Offend' (Table 1). You have to tell 43 patients who cannot walk that they have multiple sclerosis before one becomes offended, a mere 9 if you say it is "functional", but two is sufficient if you call it hysteria. Source: British MedicalJournal, Dec 21, 2002 What should we say to patients with symptoms unexplained by disease? The "number needed to offend".

    Or take the word psychosomatic'. Implying that there is a link between mind and body has a distinguished history, and is part of popular culture. Indeed, some lay models of illness are too psychosomatic depression does not cause cancer, people do not die of broken hearts, nor do parental over-expectations cause autism. But on the other hand psychosomatic also scores highly on the Number Needed to Offend scale not surprising, since when used in the media it usually means "imaginary" or "made up" (Stone et al, 2004).

    So using labels, even if hallowed in textbooks and reference manuals, can threaten not just any chance of a therapeutic relationship, but can trigger a battle of diagnosis, from which the patient themselves is the loser, determined to prove the doctor wrong in the only way possible by staying ill. As rheumatologist Nortin Hadler put it "if you have to prove you are ill, you can't get better".

    So no wonder the doctor and patient both collude. Euphemisms can be important, if they allow the patient to address tangible clinical issues or engage in appropriate treatment and rehabilitation, but without endangering their self esteem. Let's hear it for collusion.
    The Number Needed to Offend - Table 1.

    A doctor would be suggesting I was Putting it on', Mad' or Imagining symptoms' if I had a weak leg and they gave me this diagnosis (%)
    Number Needed to Offend: Issue Percentage % Number Needed to Offend (95% CI)
    Symtoms all in the mind 93% 2(2-2)
    Hysterical weakness 52% 2(2-3)
    Psychosomatic weakness 42% 3(2-4)
    Medically Unexplained weakness 35% 3(3-4)
    Depression associated weakness 33% 4(3-5)
    Stress related weakness 20% 6(4-9)
    Chronic Fatigue 15% 8(5-13)
    Functional Weakness 13% 9(5-16)
    Stroke 13% 9(5-16)
    Multiple Sclerosis 5% 43(13-Infinity)

    Source: British Medical Journal, Dec 21, 2002 What should we say to patients with symptoms unexplained by disease? The "number needed to offend".
    Collusion and Self-Interest.

    Finding a label that will not offend the patient whilst enabling them to engage in sensible treatment can be a good strategy. I know a number of neurologists who manage patients whom others might call depressed, anxious or somatising under a variety of labels such as neuralgia, chronic migraine, cervical arthralgia, or fibromyalgia. And they don't do too badly. Support is given. Antidepressants are prescribed, although rarelyfor depression', but for analgesia or sleep disturbance. Rest, but in moderation, is encouraged, and linked to some form of regular activity. "Collusion" some might and do say, but it can promote rehabilitative or psychological treatments which if taken head on, would only have led to offence.

    And it's nothing new. When historian Edward Shorter reviewed the records of one Edwardian neurologist, Parkes Weber, with an extensive Harley Street practice, what was striking was just how little has changed. The newly affluent middle classes, more often than not women, flocked to his consulting room to be told that they were suffering from nervous exhaustion, that they lacked vital force, and that their nerves really were weak in short they had what was at the time the perfectly respectable label of neurasthenia.

    But there was also a dark side, evident in some of the writings of those on the other side of the couch. People such as Virgina Woolf or Charlotte Perkins Gilman, struggling to escape stifling marriages or the constraints of a society that refused to accept women as anything other than second class citizens. Women seeking to escape the confines of what the Germans would call "cake, church and kitchen" were instead given tonics and rest cures when what they wantedwas recognition and independence.

    And it got worse. At the same time as Parkes Weber practised north of the river, south of the river at the newly opened King's College Hospital surgeon Willie Lane plied his trade. He too was interested in the problems of women with unexplained symptoms, most of which we would now ascribe to depression,anxiety or somatisation. But the life of the mind was not for Willie he believed that the problems all came from the colon. To be precise, that all this "toxic" somatic symptoms were the result of the products of digestion leaking out of the colon and causing ill health. It was called "auto intoxication". It was nonsense, and it was dangerous nonsense. Willie was a surgeon, and surgeons are brought onto God's good earth with the desire to operate. And so Willieused to remove the colons of these unhappy young women. 10% of them died. In fact that was quite a good figure, lower than the standard mortality forabdominal surgery at the time, since Willie was a good surgeon. And amazingly, many of those who survived got better, and used to write to Willie in appreciation. And so Willie ended his career in glory, as Sir Arbuthnot Lane, surgeon to the King, and still the only person with wards named afterhim in two separate London teaching hospitals. Colluding had done him no harm at all. However, it is unlikely that he performed this surgery to cynically exploit his patients and more probable that he firmly believed that he was acting in his patients' best interests.

    And whilst many modern Parkes Webers live on, there are also still many Willie Lanes as well. It is still possible to get one's autointoxicated' coloncleaned on a regular basis at several establishments near the modern Harley St and celebrities and minor royals have endorsed the treatment.

    Whatever your problem, they have the solution. Every test they do is always positive for some mysterious reason the labs they use always find deficiencies in one trace element or another. They diagnose allergies using tests that NHS allergists and immunologists regard as at best flawed, and at worst, such as Vega testing, utterly nonsensical. They spout the language of science, but it is a parody language, mixing cod' immunology with pseudo radiation science interspersed with New Age homilies (see www.badscience.com). They portray themselves as brave pioneers, unable to practice within the dull, evidence based confines of the NHS, and only when freed from the shackles of NICE and prescribing committees who are only able to give their patients the kind of treatments they really need - at a cost of course. They replace hormones that don't need replacing giving thyroxine to people with normal thyroid function is currently popular; and like Willie they remove things that don't need removing, dental amalgam from one's teeth being another current fashion. These medical entrepreneurs have a talent for converting the latest scares into opportunities. No sooner did Panorama identify Wi-Fi as one more cause of fatigue and malaise, a raft of Wi-Fi protection devices' sprang into being.

    As soon as one diagnostic fad disappears, it is replaced by another. The word autointoxication has largely vanished, but colonic lavage and detoxificationis a mainstay. We don't see much spontaneous hypoglycaemia these days, and chronic brucellosis has gone the way of all flesh, but candida, dental amalgam, food allergy and multiple chemical sensitivity continue to flourish, and the new electrical hypersensitivities are starting to make themselves felt.

    To be honest, the exact label is not the issue, and many are interchangeable what is important is that they provide an explanation for the stresses, strains and symptoms of life, and an explanation that almost invariably avoids any of the possible self blame, stigma and guilt of those diagnoses that more conventionally minded doctors use.

    Surprisingly, in spite of the harm some treatments can cause, even if it is only by delaying access to effective medical treatment, few people seem tocomplain about these therapists. It's a form of cognitive dissonance. Or perhaps it is just too painful to realise that the kindly, polite, charming doctor with the smart consulting room, the latest gadgets, and the utter conviction that he or she really does understand the cause of your problems is really giving you things you don't need for problems you don't have. And so the swings that you gain in having your complaints listened to and legitimised are lost on the roundabouts of continuing ill health and dependency on doctors.
    Anything for the Quiet Life.

    I doubt there are few occasions in which doctors are more pressured to collude with their patients when the latter pushes across the desk a form thatneeds to be signed. I asked my wife, an inner city GP, what forms she has to complete in a typical week. OK, she said, there are the sick notes. I hadthought of that. And fitness for work. Fair enough. And fitness to drive. OK, well, I can see that. But she said, yesterday I had to certify someone as fit to fly as a passenger. Oh yes, and last week it was fitness to fly as a pilot, and on it goes. There are the insurance medicals and forms that the readers of this document will be more than familiar with. But gun ownership? Do doctors really know who is suitable to own a gun? I was once asked by a government department to devise a screening form to assess this. I proposed one question "do you want to own a gun?" and if the answer was positive, then you were unsuitable. But GPs are supposed to know who is suitable to own a gun, just as they are supposed to know who is suitable to foster or adopt.

    And then there are the exemptions a GP needs to certify that you are unable to use a seat belt, pay off your debts or your council charge, need longertime in exams, or not be able to sit them all together. So the potential flash points mount up forms to say you are not fit to go to court, do community service, or obey a probation order. Last week my wife had to certify that someone was fit to use a gym (and there was I thinking the reason you used a gymwas because you were unfit).

    Most weeks my wife has to certify that a photo is a true likeness of one of her patients. And in nearly every case there is little to be gained and everything to lose by refusal to complete any of these forms. So who can blame the doctor for colluding with the patient? The GP may harbour lingeringdoubts about why nearly every child getting extra time in exams is middle class, or is adult attention deficit disorder really a reason not to be able to comply with a community treatment order? Or is it really work stress' when the doctor knows all about the divorce and difficulties with the kids? But what the heck if I don't sign the chances are they will complain, and that will involve weeks of paperwork, bad publicity and an uncertain outcome. So it's anything for the quiet life.

    Where did this all start? It all began with the introduction of Social Security benefits in Germany, particularly with the Sickness Insurance Act of 1883 in Germany under Count Otto Von Bismark. Clearly, if benefits were to be introduced a gatekeeper would be needed, and doctors were willing to undertake that role. When the legislation came to Britain doctors were similarly willing. Many would argue that doctors saw themselvesas defenders of the State against the potential hordes of claimants of these new benefits.

    So I am afraid we doctors have brought this on ourselves. But what no one envisaged was the sheer size of what would become the welfare state, nor the resources that it would eventually command. Now collusion is just about the only way my wife can cope with the bureaucracy, and who can blame her?
    Conclusion.

    So doctors collude with their patients all the time. It's not such a bad thing after all. When I (briefly) trained in psychotherapy I was taught that, whatever else, we should show positive therapeutic regard for our patients. Or to put it simply, we are on the patient's side. Sometimes in psychiatrywe are the only people who are. If we are not for our patients, who else is going to be?

    And often that means collusion in one shape or form. Sometimes we don't always "tell it as it is", if we pick up cues that a person really doesn't want to know the worst, at least not now. Sometimes we endorse diagnostic labels of dubious provenance but what does that matter if at least it enables the person to get help? And so what if we sign a person off with work stress'? After all, their employer may well not be a paradigm of virtue, and the break might at least enable the patient to patch up an equally dodgy marriage.

    But there are limits. Dubious labels can also lead to equally dubious treatments. Collusion is also easier to defend if one party gains nothing from the encounter but when the doctor reaps a rich reward in fees, it is harder to claim a moral paternalistic high ground.
    Professor Simon Wessely.

    Professor Simon Wessely

    Simon Wessely is Professor of Epidemiological and Liaison Psychiatry at the Institute of Psychiatry, King's College London, and Honorary Consultant Psychiatrist at King's and Maudsley Hospitals. He started his psychiatry training at the Maudsley in 1984, and has not really left Camberwell since, other than a year at the National Hospital for Neurology, and a year studying epidemiology at the London School of Hygiene.

    Simon's research interests are in the grey areas between medicine and psychiatry, clinical epidemiology, psychiatric injury and military health. His first paper was called "Dementia and Mrs Thatcher", but since then he has published over 500 papers on many subjects, including epidemiology, post traumatic stress, psychological debriefing, chronic fatigue syndrome, history, chronic pain, somatisation, Gulf War illness, military health and terrorism.

    Simon is also Director of the King's Centre for Military Health Research Unit at King's College London. In 2006 the unit published the first resultsof a study of the physical and psychological health of 12,000 UK military personnel, half of whom have served in the Iraq conflict.

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