Tuesday, 5 January 2016

Medically Explained Assumptions

Jean Martin Charcot was a pathfinding 19th century neurologist with a particular genius for anatomical dissection and postmortem diagnosis, but he may be best known today for his work on ‘hysteria’. In his book Freud, Richard Webster describes Charcot’s ‘classic case of neurotic hysteria’, in which a man named Le Log—–  who suffered memory loss, paralysis and seizures after being knocked to the ground by a speeding carriage, was deemed by Charcot to be suffering psychological trauma from the accident. As Webster suggests in his book, such a patient today would be recognized as having ‘a case of closed head injury complicated by late epilepsy and raised intracranial pressure’. But the concept of internal head injuries was not understood at the time, so because Le Log—– had no visible signs of injury, Charcot assumed that the symptoms must be psychological. The poor man was misdiagnosed with ‘neurotic hysteria’ and subjected to psychological therapy,  which won’t have done very much to cure his concussion.

Charcot did not invent the concept of ‘hysteria’ but his interest popularized its use and over the years it was applied to epilepsy, multiple sclerosis, Parkinsons disease, cerebral tumours, and a great many other conditions which were not at the time recognized as the physical problems they were later acknowledged to be.

The diagnosis ‘hysteria’ is not in use today but the medical profession’s habit of labeling any patient with symptoms that don’t fit the pattern of a currently recognized pathology as ‘psychologically ill’ remains as prevalent as ever. These days, they use terms like ‘somatization’, ‘conversion disorder’, and ‘medically unexplained symptoms’ but the concept remains the same. Any set of symptoms which aren’t in the medical textbooks is assumed to be ‘all in the head’.

In the 21st century there is really no excuse for this. A quick glance back through history will reveal that time after time this practice has led to misdiagnosis, as medical science has gradually identified more and more genuine physical conditions which were previously dismissed as ‘psychological’. Yesterday’s ‘hysteria’ is today’s epilepsy, today’s MS…

Ironically, while the physical conditions are required to meet precise and stringent criteria for diagnosis, the psychological labels seem to be largely defined by exclusion. ‘If you don’t meet the physical criteria,’ you are told, ‘you must have this other condition we’ve dreamed up…’ No further evidence seems to be needed. The health professional’s opinion is all powerful.

As far as I can deduce, there is no proof that conditions such as somatization actually exist, any more than hysteria did, but even if they may sometimes have some validity, the practice of allocating them to patients by default, just because medical science has not yet defined a specific template for their symptoms, is clearly mistaken.

So why does it continue?

I can only assume it is because it is convenient for the medical profession. Doctors are able to refer patients on for psychological therapy instead of having to admit that the patient’s problem is outside their knowledge, and at the same time it brings in extra work for psychiatrists and psychologists. So everybody wins – except for the misdiagnosed patients of course.

In this environment, is it really surprising that people with ME (myalgic encephalomyelitis) are so often misdiagnosed as having a psychological condition? It’s only the same thing the doctors have been doing for years: assuming that the state of medical knowledge is so advanced that anything not in the textbooks can’t be physically real and must be down to some sort of aberrant thinking on the part of the patient. When you look at it from this perspective, you could argue that the doctors aren’t really picking on people with ME after all. This is just what they do with conditions they don’t understand. They’re done it for hundreds of years. It’s nothing personal to us…

I’m sure doctors think they’re helping their patients by referring them on for psychological therapies – and in some cases they are, of course. Such therapies can be helpful, even where a physical condition exists. CBT (cognitive behavioural therapy) can be of assistance in ME, for instance, if it’s used to address obstacles to pacing such as guilt and ‘people pleasing’. But where it is used – as it predominantly is – hand in glove with GET (graded exercise therapy) to convince the patient there is nothing physically wrong with them and all they have to do to get better is to ignore their symptoms and push themselves regardless, then it can lead to a serious and long term deterioration in the condition, as evidenced by the recent ME Association patient survey.

One of the frequently repeated misapprehensions about people with ME is that we object to a psychological diagnosis because of the stigma it brings. This was most recently voiced by the former BMJ editor Richard Smith (in an otherwise helpful piece which called on the PACE Trial researchers to release their data). He wrote:

“The emotion stems from sufferers from the condition (ME) resenting greatly the idea that it may have psychological causes with the stigma that implies. The resentment seems to be that psychological problems are not seen “real” in the way that physical ones are and that they may result from “moral weakness” rather than a morally neutral virus.”

Goodness knows where Richard Smith got these weird ideas but they’re not something I’ve ever heard from people with ME. The main reason we object to a psychological diagnosis is straightforward enough: because it isn’t accurate. There is now substantial evidence that ME is (as the recent IOM Report describes it) a ‘serious chronic complex systemic disease’ with a growing body of biomedical research studies to support this view. A handy A4 sheet with details of ten such important findings was recently produced by Prof Anthony Komaroff, and the IOM Pathways to Prevention Report makes clear: ‘this is not a primary psychological disease in etiology’.

Furthermore, the psychological misinterpretation of the condition leads to inappropriate therapies which, as mentioned above, can have seriously damaging consequences for patients; it diverts interest and investment away from the biomedical research which is desperately needed; and it provides ammunition for misinformed media coverage like the Telegraph article we saw a few weeks ago, which can seriously damage relationships between people with ME and their friends & family and society in general.

These are the reasons why we want our condition to be recognized for what it is. It has nothing to do with the potential stigma of psychiatric illness. We have no reason to fear such stigma, as the truth is that we already have more than enough of our own. Sir Simon Wessely quite rightly speaks out against the stigma of mental illness, pointing out that such conditions are as ‘real’ and unpleasant as physical ones, but the truth is that this stigmatization seems to be just as prevalent among the medical profession as it is in society at large, and the medics who buy into it seem to reserve special disdain for those they perceive to be mentally ill yet who refuse to accept their diagnosis. It is true that if you’re mentally ill, you tend to be at a disadvantage in dealing with doctors. But if you don’t accept this label and – worse still – don’t respond well to the treatments they give you, then you’re really in trouble.

Welcome to life with ME.

Never mind that there is substantial evidence of biophysical abnormalities and none of an underlying psychological cause, the psychosocial model of ME so beloved of mainstream medicine, especially here in the UK, requires us to forget all that and believe we’re not physically ill – or else risk being seen as a difficult patient. We are asked to believe that the day to day reality of our illness is other than what it is.

In her excellent recent blog post, ‘The Politics of Stigma with ME/CFS’, Catherine Hale quotes the Buddhist author and ME patient Toni Bernhard on this subject: “we have been branded not credible witnesses to our own condition”. Catherine goes on to suggest that ME has been represented as ‘an illness of misperception of reality’.

Yet whose misperception of reality is really the problem here?

We patients with ME are sometimes described as having ‘medically unexplained symptoms’, yet what exactly is ‘unexplained’?

We don’t yet understand the exact mechanism by which our symptoms are produced but if, as the evidence suggests, we have a neuro-immune multi-systemic condition, that is surely explanation enough for why we are suffering.

What is less easy to explain are the many misperceptions of the medical profession:

  • why any set of symptoms not in the medical textbooks is automatically assumed to be ‘psychological’, even though history shows this has consistently proved to be a mistake
  • why people with ME are assumed not to be physically ill when there is plenty of credible evidence to show that we are
  • why we are treated with therapies such as CBT and GET for which there is little evidence of efficacy and which patient experience suggests can be very damaging
  • why PACE, the largest study in support of these therapies, is assumed to be ‘excellent research’ in spite of innumerable fatal flaws

It seems to me we are the victims not of ‘medically unexplained symptoms’ but of ‘medically unexplained assumptions’.

It is not us, people with ME, who are making these assumptions. But day after day, year after year, we have had to suffer their consequences.

Now, as a new year dawns, perhaps the medical profession will finally start to open its eyes to reality.

2015 brought many encouraging developments:

  • The US IOM and P2P Reports have reported on the true nature of our condition
  • New research funding has been announced by the US National Institutes of Health
  • Prominent researchers such as Ian Lipkin and Ron Davis have spoken of a new urgency to ‘solve the puzzle’ of ME
  • Even here in the UK, thanks to David Tuller, James Coyne and the work of the many patients and professionals who have chipped away to expose the flaws of the study over many years, pressure is growing on the PACE trial researchers to surrender their data.

Let’s hope that 2016 brings us closer to the day when the mists finally part to reveal the truth, and the mistaken assumptions of decades (and centuries) past are consigned to history.

While the clocks tick by on our lives, we wait to see…

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