"Philosophy matters in brain matters" (Hustvedt, 2013) (open access)

[alex3619]

The solution (to the unfalsifiabiltiy of ideas from Janet/Stekel/Freud etc) apparently, was:

Unlike the abstract models of the early psychoanalysts, attachment theorists put forth a strong psychobiological model which suggested that early experiences influenced neural development, as well as subsequent behavior.

Emotive, rhetorical, vague, woolly language - the hallmark of pseudoscience.

"Strong" .. how?

"model" ... that means its theoretical. Where is a test of the validity of the model?

"suggested" .. vague probabilitic claim ... a might be true. It also might not be true.

The biopsychosocial model has been claimed to not even be a model. Its too vague. As its generally stated, its trivially true. Like, man, its all gravy, the universe exists, and we are in that universe. As its being used to promote psychogenic claims however, its use is highly distorted. The typical pattern is to start with an obvious truth, then another, then make a plausible sounding but irrational leap. This is an old salesperson's trick, and another hallmark of pseudoscience.

The biopsychosocial framework is one in which a scientific theory might be developed. Or pseudoscience. Or complete babble. Its the quality of where it goes afterward that is important.

 

[alex3619]

Interesting article. It's always seemed odd to me that the default position (in medicine) for medically unexplained symptoms is to attribute those symptoms to a "psychological" cause - whatever that may be. This position assumes (somewhat arrogantly I feel) that medicine already knows everything there is to know about the body.

See my earlier post about psychogenic fallacy: http://forums.phoenixrising.me/inde...edt-2013-open-access.34074/page-2#post-529101

How much of what is termed "functional and/or psychosomatic" will become "organic" once better diagnostic techniques are discovered? If you take a "functional syndrome" like IBS as an example, if better imaging techniques are found, will it be then seen as "organic"?

I have answered this extensively in other places. Psychogenic medicine has been right zero times when an answer was found, but biomedical understanding, after sometimes many decades of research, was where the answer was found. Again, and again, and again.

Yet now psychogenic proponents are fighting back with this piece of supposed wisdom: you might have the physical disorder (insert disease of choice) but you also have our preferred psychogenic diagnosis. Yet most doctors and the public realize that once a disease is understood, with diagnostic tests and real treatments, psychobabble loses.

 

[alex3619]

To really investigate the specificity and sensitivity of such associations, we first need an unbiased sample.

I understand there were a couple of prospective population studies involved too. Yet the conundrum remains: most associations in data are due to common causes or chance, and this cannot be determined without further investigation.

Tooth decay and obesity might be correlated (I have not checked, this is hypothetical), but if the study didn't track sugar intake what could you conclude about causation?

For now I wont say any more, I have posted a heck of a lot. Please comment.

 

[Cheshire]

We create categories and also rules to use those categories. Yet reality frequently transcends simple limits we want to put on it.

When a category has multiple meanings it doesn't lose that meaning typically, what people do is sit different meanings side by side and use them as they see fit. One of the issues with much of the psychobabble is it deliberate constructs alternate meanings and hides that they are being used.

Maybe "loses its meaning" is a bit strong. But how can communication be at its optimum when you don't talk about the same thing while using the same vocabulary?

It's an open door to manipulation and abuse.

 

[alex3619]

Maybe "loses its meaning" is a bit strong. But how can communication be at its optimum when you don't talk about the same thing while using the same vocabulary?

It's an open door to manipulation and abuse.

And this is one of my chief arguments against psychobabble. Its not only open to abuse, they do so repeatedly and systematically.

 

[adreno]

I understand there were a couple of prospective population studies involved too. Yet the conundrum remains: most associations in data are due to common causes or chance, and this cannot be determined without further investigation.

Yes, but if those associations between early life stress and increased morbidity correlate with epigenetic changes, brain changes, or other biological markers they carry much more weight.

In any case, the effects of social environment might in many cases be indirect, influencing the lifestyle choices of individuals (for example risk-seeking behavior, drinking, drug use, poor sleep hygiene, poor diet choices aso), which end up affecting health.

 

[Jonathan Edwards]

Helen said: ↑
In this article written 2003 by late Dr. Per Dahlén, who was a sharp and humble psychiatrist, many of the issues are discussed in an interesting way

I loved this article, and have not reread it just now, but I recall I had some cautions about what was said as well.

Yes, I think his analysis of causation is wrong, but the bits relevant to this discussion I thought were very nicely written.

 

[Marco]

In this article written 2003 by late Dr. Per Dahlén, who was a sharp and humble psychiatrist, many of the issues are discussed in an interesting way , I think.

http://art-bin.com/art/dalen_en.html

Thanks Helen

I've often been struck in discussion of somatization/somatoform disorders that the one example trotted out by supporters is hypochondria where someone believing they have X serious illness despite negative tests can be 'tripped up' by agreeing to having a particular symptom that isn't part of the clinical presentation. This example 'proves' the existence of somatization and thereafter the world's their oyster.

Leaving aside what this says about the therapeutic relationship I'll concede that these examples exist but their occurance must be so vanishingly rare that I doubt few psychiatrists come across a single case in their entire career. Yet this is the default 'explanation' for a wide range of 'medically unexplained syndromes' (a name which should mean exactly what ot says on the tin).

As Per Dahlen suggests, such logical leaps must serve a need for someone.

 

[Snowdrop]

This has been very interesting reading for me.
These days I am barely able to follow along, I used to love this kind of puzzling.

It might not add much to the discussion but these days of course we know that the mind is not only in the brain.
It also resides in the gut. Some of the neurotransmitters are produced there and the microbiome has been implicated I believe in directly producing some of our responses to our environment. It seems the mind is expressed throughout our body.

 

[alex3619]

Yes, but if those associations between early life stress and increased morbidity correlate with epigenetic changes, brain changes, or other biological markers they carry much more weight.

In any case, the effects of social environment might in many cases be indirect, influencing the lifestyle choices of individuals (for example risk-seeking behavior, drinking, drug use, poor sleep hygiene, poor diet choices aso), which end up affecting health.

They carry weight as changes. Such findings always require detailed analysis. Otherwise they are just "might be" hypotheses. Its not that we know they cannot have an impact, its that we do not really understand the impact and conclusions are being implied far beyond the evidence. As a subject for further study this has some relevance, as something that can drive modern political and coercive medical agendas its dangerous.

 

[Jonathan Edwards]

Thanks Helen

I've often been struck in discussion of somatization/somatoform disorders that the one example trotted out by supporters is hypochondria where someone believing they have X serious illness despite negative tests can be 'tripped up' by agreeing to having a particular symptom that isn't part of the clinical presentation.

Leaving aside what this says about the therapeutic relationship I'll concede that these examples exist but their occurance must be so vanishingly rare that I doubt few psychiatrists come across a single case in their entire career.

I think you may be wrong there Marco - just on a technical point. Examples are not uncommon. When I saw new patients in a general rheumatology clinic I think about one in fifty would come under this heading. The most florid example I have seen was in fact in A/E when a young woman was brought in apparently in coma. It was clear from involuntary (too floppy) body reactions to being moved that she was not. During the examination I mentioned aloud to my house officer that if she had meningitis she would have a stiff neck and her neck proved as stiff as a board. Sadly, it later became clear that she had a psychotic delusional state. On a more mundane basis I learnt early on when testing sciatic nerve sensitivity to perform a 'reverse test' in certain cases, which was often positive.

What I find strange about the psychiatric position is not that they recognise these situations but that they seem to think that they all arise from the same mechanism and that people with no psychological basis for their symptoms also fit in the same category. With time I came to recognise a range of different patterns of 'poor witnessing of symptoms' which I could put into at least four or five discrete categories that seemed to have unrelated causes. Straightforward malingering was quite common in the 1970s but became less so. Ordinary terror is another reason for believing you have every symptom asked about - on one occasion it was me. There are also a range of personality types that can lead to various pathological collusions with doctors or therapists to generate make believe illnesses. And I emphasise the collusion here - the doctor tends to lead the way. (Sometimes this is called CBT, as you know.) There is also a common form of poor witnessing that goes with cultural disparity - in certain non-European cultures charades involving both spouses and doctors are part and parcel of signalling misery about life situations that cannot be signalled in other ways because of cultural taboos.

The key points for me are that, in a rheumatology clinic at least, (1) all these situations are very much a minority, (2) they are all very obviously completely different and (3) none of them are worth calling 'psychosomatic'. They all deserve sympathy and none of them benefits from being told their illness is 'psychosomatic'. Moreover, I know of clinics where such patients come to be a significant proportion of those who attend because that suits the doctor. I seriously wonder whether some psychiatrists end up collecting a high proportion of people who witness their symptoms in a range of unusual ways. Hence their irrational belief that ME is an irrational belief.

With time, I learnt, mostly through making mistakes, that in almost all these situations you can avoid the poor witnessing right from the start by steering away from traps generated by unemployment, fear, collusions and culture. Then the trick questions (mostly) become redundant. You try to learn how people tick. Sometimes I am not sure some psychiatrists even try - although I am very thankful to one who did when we needed that.

 

[Woolie]

I worry that those pushing childhood trauma theories are not thinking through the problem as you say what is special about that state rather than an ideal childhood state. After all we are animals and watching David Attenborough's latest documentary makes me realise that many animals naturally have what I can only see as a traumatic childhood experiences and experience danger. Would man really have evolved to not be robust to at least some difficult childhood issues.

It seems to me that there are a lot of people with childhood trauma some go on to have a disease others don't. Equally there are some who develop the same disease without childhood trauma and some who don't. I guess someone could draw out the conditional probabilities P(Disease_x|trauma), P(~Disease_x|trauma), P(Disease|~trauma), P(~Disease_x|~trauma) and compare these to just P(Disease_x) and P(~Disease_x) (I've used ~ as not). But even if there were a slight increase in the probability of disease given trauma as compared to the probability of getting the disease we need to think more deeply. If there is a (slight) correlation why in some cases and not in others and why do some people get a disease without the trauma. This would give us some sort of clue and it may be that there is an underlying variable which is correlated to childhood trauma and cause. Hence a correlation but not a cause-effect relationship. For example, if there is a genetic disposition in getting a disease - this is likely to leave a number of parents with the disease in poverty - does poverty correlate with childhood trauma for example due to lack of safe housing or other social reasons.

@user9876 I think this is a good point. Also, if you think about what the average child would have gone through, say 150 years ago - physical discipline at home, witnessing death at regular intervals and even sometimes killings - its a wonder any of them were able to function physically at all.

Also a good point about the problem of attribution-in-hindsight which we are all susceptible to. A friend of mine suffers from anxiety. I can see the signs as it comes on him - a slow, incremental effect. He, on the other hand, attributes the anxiety to discrete events, such as worry about something happening at work, etc. I can't see any change in the frequency or intensity of these events from before he was anxious - just in the normal range of things - but he is convinced of the connection.

 

[A.B.]

According to the psychiatrists, a somatoform disorder is not malingering, nor hypochondriasis. It's literally defined as physical symptoms with normal lab tests.

In the DSM-5 it's now called somatic symptom disorder: http://en.wikipedia.org/wiki/Somatic_symptom_disorder

To meet the criteria for somatic symptom disorder, patients must have one or more chronic somatic symptoms about which they are excessively concerned, preoccupied or fearful. These fears and behaviors cause significant distress and dysfunction, and although patients may make frequent use of health care services, they are rarely reassured and often feel their medical care has been inadequate.

http://www.mayoclinic.org/medical-p...al-mental-disorders-redefines-hypochondriasis

Isn't the above pretty much exactly what would happen to a person with a disease doctors cannot yet understand? Here it's framed as the "fears and behaviours" causing distress but there is certainly more than one way to see things.

Anyway, the example cited by Jonathan Edwards sounds more like malingering to me (ie. faking a problem).

 

[Cheshire]

Anyway, the example cited by Jonathan Edwards sounds more like malingering to me (ie. faking a problem).

In saying this, you're not doing very differently than so much doctors we meet.
They take a rapid look at our symptoms, then quick reading of our empty medical files and conclude: there's nothing wrong with you, and at best they think we have a somatoform disorder, and at worse, that we are faking all this, instead of stating "I don't know".

The example given by Jonathan Edwards is quite strange, and perplexing, but I wouldn't draw any conclusion just by reading his short report.

 

[Marco]

With time, I learnt, mostly through making mistakes, that in almost all these situations you can avoid the poor witnessing right from the start by steering away from traps generated by unemployment, fear, collusions and culture. Then the trick questions (mostly) become redundant. You try to learn how people tick. Sometimes I am not sure some psychiatrists even try - although I am very thankful to one who did when we needed that.

Yes I can see how these situations might arise much more frequently although I would still maintain that 'real' disorders of a psychological nature are much more rare. It's interesting how frequently secondary gain is mentioned as a maintaining factor in ME/CFS despite the obvious major losses of all sorts compared to our previous healthy lives.

 

[Jonathan Edwards]

Anyway, the example cited by Jonathan Edwards sounds more like malingering to me (ie. faking a problem).

The lady in A/E was not in fact malingering. Malingering is deliberately pretending to be ill in order to avoid work. This lady had a major psychiatric illness with delusions about specific people (something close to what people call schizophrenia). Her delusions incorporated what was suggested to her.

I think the little phrase 'There's nowt as queer as folk' has a lot to it.

Psychiatrists are supposed to understand that but sometimes they seem blind to what is front of them and only interested in the guilt fantasies which were probably not even new to Freud and are probably more about them then the patients (as someone already said).

But the key thing maybe, as you say A.B. is that the idea of somatoform disorder doesn't explain anything or make much sense. People get fearful in the short term but the one thing I never really came across was excessive concern about something that did not exist causing disability. I met people with excessive concerns about having certain illnesses but that did not cause them any disability. Disability is caused by real symptoms. The two things seem to me to be unrelated - or at least not related in the way that 'somatoform' implies but does not explain.

 

[Sidereal]

Psychosis rules out a diagnosis of somatoform illness, as does malingering and hypochondriasis. People with psychosis like the lady in a "coma" are convinced of the wrong things, by definition, and that can sometimes include somatic delusions. But that's not what psychiatrists think is wrong with us. They think we are converting subconscious conflicts/anxiety/depression into physical symptoms, a neurotic process.

 

[adreno]

I met people with excessive concerns about having certain illnesses but that did not cause them any disability. Disability is caused by real symptoms.

The problem is that doctors don't believe/accept there is any disability, when standard tests come back normal. It's dismissed as hypochondriasis. When I tell doctors I have problems standing (OI), they say "hmm". Perhaps I need to take a run in the forest, or perhaps I have relationship problems?

 

[A.B.]

In saying this, you're not doing very differently than so much doctors we meet.

You're right, it is probably better not to make hasty judgments here.

But the key thing maybe, as you say A.B. is that the idea of somatoform disorder doesn't explain anything or make much sense.

The description of a patient with somatic symptom disorder (SSD) is exactly the description of a patient with an unknown chronic disease. The only difference is the subjective judgment of the doctor who decides whether the patient is excessively worried or not.

This is not a legitimate diagnosis as you're saying. It's just a way to handle cases with unknown chronic disease that puts the interests of doctors, psychiatry, health care providers above that of the patient. The doctors don't want to deal with it. Psychiatrists need a job. Health care providers want to limit costs. None of them want to admit that they're doing the patient a disservice, so it has to be sold as "helping" the patient.

Maybe the future will be close collaboration between researchers and these patient groups.

 

[chipmunk1]

Read the etiology section of any book on psychosomatic illness and you'll see why they discuss childhood trauma so much. Many psychiatrists seriously believe that attachment & early development theory is the basis for psychosomatic illness. Why? Because they don't have much else.

Most of the first 60 years of somatisation disorder research was done by psychoanalysts. Psychoanalysis is based on the idea that (repressed)childhood trauma causes illness.

The entire field is based on that belief. Freud is dead and psychoanalysis is dying but psychosomatic illness is still quite vigorous.

To meet the criteria for somatic symptom disorder, patients must have one or more chronic somatic symptoms about which they are excessively concerned, preoccupied or fearful. These fears and behaviors cause significant distress and dysfunction, and although patients may make frequent use of health care services, they are rarely reassured and often feel their medical care has been inadequate.

What medical care? "You are not ill because Freud said so" is not medical care.