What Colour Are Your Specs?
At some point in the past day or two, while pondering the latest upsurge in the Freud debate, I was inspired to look up ‘hysteria’ in The Penguin Dictionary of Critical Theory. I was a little surprised at what I found.
A form of neurosis for which no physical diagnosis can be found and in which the symptoms presented are expressive of an unconscious conflict. In conversion hysteria, the symptoms usually take a somatic form (hysterical paralysis, irritation of the throat, coughs)…Hysteria has been explained in many different ways over the centuries; the most influential aetiology or causal explanation to have been put forward in the twentieth century is that supplied by Freud’s psychoanalysis.
There’s a problem with that. It inexplicably omits necessary phrases like ‘once thought to be’ and ‘it was thought that’ and ‘but increased knowledge of diseases of the brain and nervous system have rendered such explanations nugatory.’ The phrase ‘for which no physical diagnosis can be found’ ought to read ‘for which no physical diagnosis could be found until researchers discovered organic diseases such as multiple sclerosis and motor neurone disease, and developed a better understanding of the effects of closed-head injuries and spinal injuries’. And note the sly word ‘influential’ about the aetiology put forward by Freud. Not accurate, not correct, not well-founded, but influential. Note further that it doesn’t say influential on whom. Not on neurologists it wasn’t – fortunately.
There’s another absurd bit:
It was only in the nineteenth century that the phenomenon of ‘railway spine’ (a psychosomatic syndrome observed in the victims of the frequent railway accidents of the 1880s) led to the recognition that men too could suffer from hysteria.
Umm…railway spine? Spine? Frequent railway accidents? Does that suggest anything to you? Like, for instance, the possibility that the syndrome was not psychosomatic at all, but, you know, spinal injury? Isn’t it kind of an odd coincidence that it was specifically railway accidents that caused men to develop ‘hysteria’?
No, it doesn’t suggest that to the writer of this dictionary. Very odd. Causes me to ponder the ways of epistemic functioning.
I’ve also been browsing in Frederick Crews’ excellent, indispensable anthology Unauthorized Freud, which has been causing me to mutter darkly about credulity and suggestibility. Credulity is an interesting and often puzzling phenomenon, which turns up in places (and people) where one doesn’t expect it, sometimes.
I’ve been discussing these things with Allen Esterson lately, too – in particular the entrenched misconception that a lot of people have via Jeffrey Masson’s book The Assualt on Truth: Freud’s Suppression of the Seduction Theory: that the problem with Freud is that he concealed what his women patients told him about being sexually molested by male relatives. In fact Freud’s patients didn’t tell him they were molested or ‘seduced,’ he told them – and then he changed his mind and suppressed the theory. But try explaining that to people who are convinced of the first account. Go on, just try. I have, and I know: it is impossible to get them to believe you. They think you’re part of the cover up crimes against women crowd, or else just ill-informed and out of touch and not up to speed. I expostulated on this point to Allen, and he remarked in his reply:
What is extraordinary is that the indications that there is something odd
about Freud’s story is staring the reader in the face even in the most
commonly cited version of the story, in “New Introductory Lectures on
Psychoanalysis”: “In the period in which my main interest was directed to
discovering infantile sexual traumas, almost all my women patients told me
that they had been seduced by their father….” But why should almost all
his female patients have reported these ‘seductions’ only during the period
when he was actively seeking infantile traumas? As is not uncommon when
Freud is misleading his readers, he gives himself away — at least to
someone who has acquired sufficient knowledge to see what he is up to.
That’s good, isn’t it? It made me laugh. “In the period in which my main interest was directed to
discovering infantile sexual traumas, almost all my women patients told me
that they had been seduced by their father….” Oh did they! My, what a coincidence! And in
the period when my main interest was directed to discovering the secret
role of the Illuminati in European history, almost all the people I sat
next to on the bus told me that they had been abducted by Illuminati.
Fancy!
Yes, life works out so neatly sometimes, you know? You develop a main interest in discovering something, and by golly, all of a sudden you start discovering it everywhere you go. In some cases, this happy outcome is called paranoid schizophrenia, and in other cases, it is called one of the great intellectual adventures of the 20th century. You just never know. It all boils down to prestige, and whether your ideas are ‘influential’ or not.
Hey, why are you obsessively freaking out over poor old doc Freud? Were you injured in a railway accident or something?
OB, no doubt some organic disorders were misdiagnosed as hysterical in the past. But I don’t think that the suggestion that all or most of those disorders labelled as “hysterical” in former times were actually organic conditions unrecognized at the time is credible. For one thing, in many cases we rarely see patients manifesting such symptoms as hysterical paralysis any more, but historical accounts show it was once very common. Also, patients were often cured by treatments such as spa baths and laxatives and so on. How so, if they were really due to MS or MND?
I don’t think you should let your antipathy to Freud (which I share) lead you to think that somatization is somehow bogus, or even a Freudian invention. There’s a worthy literature on this subject which is certainly not written by Freudians, and which is well worth reading. Ted Shorter’s “From Paralysis To Fatigue” and Elaine Showalter’s “Hystories” are a good starting place, and I’m sure you know Hacking’s “Mad Travellers” and “Rewriting The Soul.”
“For one thing, in many cases we rarely see patients manifesting such symptoms as hysterical paralysis any more, but historical accounts show it was once very common.”
But that would be consistent with the explanation that those ‘hysterical’ paralyses were in fact caused by degenerative diseases which were not known then but are now. That could explain why we now see paralysis, but not ‘hysterical’ paralysis – on account of how it’s no longer seen as hysterical.
Showalter’s book does rely on some Freudian concepts.
But that’s just it: we don’t see the same kind of paralysis today, but only as a result of neurodegenerative disorders, tumours, stroke and trauma and so on. The paralysis that we see makes neuroanatomical and neurophysiological sense. The kind described by contemporary observers as “hysterical” doesn’t. There’s no plausible present-day organic explanation that covers those phenomena.
Just to focus on the “hysterical” paralysis which was so common in the early 1800s: How do you account for the overwhelming female predominance of this condition during its heyday? Why did it mainly afflict young women? Why did they just get better? Why don’t we see these manifestations today?
In fact, why do there seem to be historically shifting, and culturally specific patterns of organically inexplicable disease? I think this is a fascinating question, but to appeal to medical ignorance as an explanation is to look in the wrong place, IMHO.
“There’s no plausible present-day organic explanation that covers those phenomena.”
That doesn’t cover any of them? Do you know that? If so, how?
How common was the hysterical paralysis of the early 1800s?
Agreed, historically shifting disease is interesting – but surely medical ignorance has to be a (large) part of the answer. As with UFOs. UFOs aren’t necessarily woo-woo, because there are plenty of flying objects that are unidentified to at least some people. Medical ignorance is (necessarily) vast. There are all sorts of things that just aren’t known. Why write that off as explanatory?
In other words – there is mysterious disease X. Chronic fatigue syndrome, if you like – or just X. There are all sorts of unknowns, including whether it’s one disease or several or many. Also including its origin(s) and its age(s). Is it a new virus? Is it an old one mutated? Is it local, global? What exactly are its symptoms? And so on. No one knows. So there are new diseases around, that no one knows much or perhaps anything about. That happens.
Why is that looking in the wrong place? Granted these things may be all social and cultural – but then again they may not. I don’t see why it’s wrong to think they could be empirical and medical.
The “advantage” of pretending that “hysteria” (or whatever it is called this week) is real, is that you can then fudge the issue of looking for a real, physical cause of a symptom ….
And the disadvantage of ignoring the possibility that “hysteria” is real is that you can keep going round and round in circle looking for a real, physical cause that in fact might not exist. This seems particularly clear in cases of mass hysteria – eg the Mad Gasser of Mattoon.
Don’t forget to check that bathwater for a baby first …
One point in Ophelia’s piece needs qualifying, where she writes that after Freud changed his mind he “suppressed the [seduction] theory”. Although in his ever-changing retrospective reports he never spelled out the theory as originally conceived, he did later acknowledge that he had at that time erroneously thought he had discovered that the roots of the psychoneuroses lay in childhood sexual abuse. Characteristically, he turned the episode into a self-serving tale of the discovery of truth (about infantile psychosexual fantasies) from error (1925, SE 20, p. 35).
It is fascinating to trace the stages in Freud’s changing story through the four retrospective reports he provided. In 1906, although acknowledging he had modified his views expressed in 1895-1896, he asserted that the clinical findings of childhood sexual abuse he had reported at that time “were not open to doubt”. (So much for the received story that Freud *discovered* that in some of these cases the patients alleged “reports” were actually fantasies.) In 1914 those very same ‘findings’ “were not true”. No culprits were cited here, but in 1925 *for the first time* he asserted that “with female patients the part of the seducer was almost always assigned to their father”. Finally, while in the 1925 account he wrote ambiguously that in the seduction theory period the majority of his patients “reproduced” childhood scenes of sexual seduction, by 1933 the story was that almost all his female patients in that period “told” him that they had been seduced by their father.
Although Camus’ friend Manès Sperber argued in “Encounter” in 1956 that Freud suggested the abuse stories to his patients, it was not until Cioffi went back to the original 1896 papers and challenged the received story in the early 1970s that the true facts started to emerge – and even then it took another two decades before they became more widely disseminated. Unfortunately, by then Masson’s dramatic, but completely erroneous, version of Freud’s “suppression of the truth” had become widely publicised and generally accepted by the educated lay public.
Ophelia quoted from a definition of conversion hysteria which specifically cites “hysterical paralysis, irritation of the throat, coughs” as examples. Is it a coincidence that those specified are well-know examples from Freud’s writings? The latter two occur in the “Dora” case history, in which Freud claims that the patient’s intermittent cough resulted from an unconscious fantasy of fellatio. Elsewhere Freud asserted that a patient’s leg paralysis resulted from his having, in infancy, used his foot to stimulate the genitals of a woman. This supposed example of “hysterical paralysis” was credulously cited by the prominent British psychoanalyst and academic Juliet Mitchell in a BBC radio programme on hysteria broadcast in 2004: http://www.butterfliesandwheels.com/articleprint.php?num=58
It is remarkable that no one, other than Freud critics in recent times, has queried Freud’s consistent description of his patients in the 1890s (and, of course, “Dora” a few years later) as “hysterics”. Even when one of his patients suffering from abdominal pains which he diagnosed as “an unmistakeable hysteria” died soon after of sarcoma of the abdominal glands, Freud explained that his “attention had been held by the noisy but harmless [sic] manifestations of the hysteria”, thereby “perhaps [sic] overlooking the first signs of the insidious and incurable disease.” (1901, SE 6, p. 146 n.)
That such misdiagnoses don’t belong only to the distant past is indicated by Peter Medawar’s book review (published later in *Pluto’s Republic*, 1984) in which he highlights a neurosurgeon’s account of the mischief wrought by psychoanalysts’ repeatedly diagnosing cases of a rare neuromuscular disease as hysteria, while the patients developed ever more dreadful symptoms.
“Antirealist” writes:
How do we account for the overwhelming female predominance of [“hysterical” paralysis] during its heyday? Why did they just get better? Why don’t we see these manifestations today.”
I’m not sure how well authenticated are these supposedly relatively numerous cases of highly specific somatic symptoms (such as paralysis) from the 19th/early 20th century that were diagnosed as hysterical, and how much is hearsay. Peter Gay cites the “brilliant results” Freud achieved in the case of “Elisabeth von R.”, whose leg pains Freud “cured” by his analytic treatment, but thanks to memoirs of her daughter that have long been inaccessible (though not to Gay!) in the Freud Archives we now know that she continued to suffer in the same way despite innumerable treatments during her life. So clinical reports of this kind may be unreliable. Do we have reasonably accurate statistics on numbers of patients from those times who suffered from paralysis and mysteriously regained the use of their limbs or whatever?
I don’t pretend to any expertise or knowledge of this subject, but I note that the neurologist Eliot Slater argued in a paper published in the British Medical Journal in 1965 that “the diagnosis of hysteria is a disguise for ignorance and a fertile source of clinical error”.
The entry makes the point itself, in a way…
“A form of neurosis for which no physical diagnosis can be found…”
Can be found – by whom? By someone who doesn’t know how to look and therefore resorts to the handy catchall ‘hysteria’? That possibility shouldn’t be ruled out a priori, surely, especially since (as is well known) not all organic causes of disease are known (and since they mutate, they never will be). It’s just too easy to translate ‘I don’t know’ into ‘patient hysteria’ or ‘psychosomatic’ – let alone sexual trauma in infancy.
Thanks for the qualification, Allen. That ‘suppressed the theory’ was a kind of (unmarked) quotation of the ‘common knowledge’ via Masson version of things. Sloppy!
Oh, lordy, we can’t possibly get into the whole subject of generalized looniness. The subject is too big. No no, let us confine ourselves to putative hysteria for the present.
This is exactly the sort of subject that I’d want “disability studies” to consider if only it were not full of blitherers.
As it happens, I have chronic fatigue syndrome, and my experience is that it is just about impossible to reason with a hard-core psychologizer. Their sureness is impossible to penetrate. You might as well be talking to a religious zealot. If you find a flaw in their metaphorizing, they will look at you pityingly — you poor atheist sod! — and inform you patronizingly that the mind is a mysterious thing. It is remarkably maddening.
Whew – that does sound maddening.
Tell such fools that, oddly enough, the body is also a mysterious thing, and pathogens don’t invariably leap out carrying little flags with their names on them.
Ah, yes, the hysterical paralysis thing. I think it’s clear that the Victorians and their immediate successors believed that hysterical paralysis was a serious “problem” (usually female)–but, like all such problems, it becomes remarkably slippery once the historian tries to quantify it. It would be interesting to know how much the Victorian belief in hysterical paralysis derived from fiction, rather than any contemporary empirical analyses. Literary representations reinforcing each other, in other words, without much in the way of reference to the outside world–sort of like the Victorian obsession with “female Jesuits” (huh? what?).
Incidentally, Janet Oppenheim’s “Shattered Nerves” is quite good on some of the more, um, interesting medical theories out there. When I was a graduate student reading through Victorian textbooks on hysteria, chlorosis, and similar maladies, my favorite discovery was that some 19th-c. doctors believed that men could menstruate.
A few points:
1. “That possibility shouldn’t be ruled out a priori, surely, especially since (as is well known) not all organic causes of disease are known (and since they mutate, they never will be).”
I am neutral as to whether any given symptom complex or exhibited set of illness behaviours has an organic or psychological origin, or some combination of the two. My best opinion at the time will be the resultant of what is already known about medical science, and the empirical evidence with respect to the condition under consideration.
But as far as I can make out Ophelia, you have an a priori belief that all symptoms and/or illness behaviours have an organic basis. If we don’t know what that basis is, that’s because of our “vast medical ignorance”.
Do I need to point out that your position is thoroughly non-falsifiable? But if I’m misrepresenting your views, and you do in fact believe that psychogenic illnesses exist, can you tell us what your criteria would be for recognizing them?
2. No sensible medical scientist jumps to the conclusion that a given symptom complex is psychogenic, but only tentatively and after scientific investigation. Any conjectured psychogenic cause would be overthrown in an instant by the demonstration of a credible organic aetiology. Can you think of an example where this has happened?
Compare the progress in elucidating the cause of, and treatment of AIDS in the first 10 years of the disease in the West (pace the HIV denialists) with the lack of progress in finding the cause of, or cure for CFS/ME. The currently best available therapy for CFS/ME seems to be Cognitive Behaviour Therapy; why would such a therapy even work at all, in your view?
3. You say that “medical ignorance is (necessarily) vast.” But this is surely true of all domains of human knowledge, including physics and astronomy. To take your position seriously, we would have to regard all our current hypotheses as having the same (low) prior probability. Nothing that we already know (or think we know) should be taken into account in assessing new evidence. For example, because our ignorance of the universe is (necessarily) vast, we could have no justification in rejecting alien abduction testimonies as unlikely to be credible. And similarly, since we know nothing, and medical discoveries could always surprise us, there could be no reasoned position to take with respect to MMR vaccination and autism on the basis of our present knowledge.
As you might expect, I don’t agree: I think we do have a pretty good understanding of the anatomy and physiology of the human body, and I think you greatly underestimate the depth of that understanding. It’s good enough, I believe, to make accurate diagnoses in the majority of cases, and to intervene effectively using surgery or pharmacology. It’s also good enough to rule out certain phenomena as physiologically impossible.
I’ve done just that a couple of times. They kept on looking at me pityingly, because I am clearly a wingnut in denial. They know what the situation is, even if I am a silly little lady who won’t knuckle under. (Women, eh.)
I’ve been reminded of some creationists I’ve known. “Evolution is wrong! I read a book that said so! It had math! So you are stupid!” Ai.
These days I just burble cheerfully about the Pall nitric oxide/peroxynitrite hypothesis or about some interesting, recently discovered abnormalities in genetic expression in the immune cells of people with CFS. I find that only a hardened fool fails to blanch in the face of a term such as “peroxynitrite”.
And, helpfully, I’m told I appear rather formidable when I burble cheerfully. I can’t imagine why. I am a sweet and harmless kitten.
Miriam: Chlorosis is one of my favourite examples of a “lost” disease – where are today’s sufferers? It’s not good enough to explain it away as a Victorian way of characterizing iron deficiency anaemia caused by poor diet and menstrual loss; the descriptions of the condition are more elaborate (and often morally-laden) than we see in anaemia today, and there are the odd social/psychological and pathological descriptions which are hard to explain on the basis of anaemia alone.
I think contemporary accounts of historical conditions such as chlorosis are persuasive evidence against the idea that “disease” entities can simply be reduced to biophysical phenomena, whilst downplaying the social, cultural and psychological milieu from whence they arise.
BYW, I hadn’t come across the Oppenheim book before – thanks a lot.
Why would CBT work at all? I haven’t got the studies in front of me, but there are a few things to keep in mind.
My own history of CFS is, to the best of my knowledge, fairly classic. First an unidentified infectious illness (though mine wasn’t flu-like); then serious fatigue and other symptoms, lightening gradually over several years. (And then I got hit by a van, but that’s another story.) Most of us do get quite a bit better over the long term.
One of the challenges in this matter is to avoid learned helplessness. Our physical limits change, and it’s tricky to know where they are. You never know quite what you can do until you’ve done too much, and not everyone is pig-headed enough to keep throwing herself at her limits to find out where they are. It’s easy to get a restricted view of what you can do, especially once you’ve gone through a few dozen push-crash cycles.
This is not to say that CFS is caused by learned helplessness, only that many CFS patients are likely hampered by having learned from past experience that no longer quite applies.
When talking about CFS studies, it’s a good idea to look very carefully at the patient groups under study. Too often, the sickest patients drop out or do not volunteer; or, since it takes a fairly long time to get a CFS diagnosis, they don’t qualify for the study in their sickest phase. (Subject selection is also a known problem with a few studies about exercise and CFS often cited by the credulous.) If the CBT researchers are not very careful in their patient selection and retention, it’d be very easy for them to wind up with a group of less-sick patients with learned helplessness issues. That’s an important group, but it should not be taken as representative of all people with CFS.
Also, to the best of my understanding, it’s rare for anyone but the most resilient people to deal with a chronic illness of any kind without suffering depression. Having your life screwed up is tough. Depression certainly will not help the symptoms of someone with CFS, and CBT does have a brilliant track record with depression. But comorbidity is not causation.
CBT may also encourage patients to rethink their ways of doing things and put them in a frame of mind that helps them strategize more energy-efficient approaches to daily life.
I should mention that I have no personal experience with formal cognitive behavioral therapy for CFS. (My current health plan has been successful and I haven’t seen reason to monkey with it.) But I am certainly no stranger to strategizing and reframing. Those are good coping skills for everybody.
“But as far as I can make out Ophelia, you have an a priori belief that all symptoms and/or illness behaviours have an organic basis.”
No, I have no such belief.
“But if I’m misrepresenting your views, and you do in fact believe that psychogenic illnesses exist, can you tell us what your criteria would be for recognizing them?”
Of course not! I don’t have any criteria. I’m neither a doctor nor a researcher.
“To take your position seriously, we would have to regard all our current hypotheses as having the same (low) prior probability. Nothing that we already know (or think we know) should be taken into account in assessing new evidence.”
That’s not what I’m saying. I’m saying that to go from “A form of neurosis for which no physical diagnosis can be found” to the conclusion that the neurosis is – not could be, but is – hysterical, seems to me unwarranted. I’m not saying no disease can be psychogenic, I’m saying that to say “I don’t know why you’re sick therefore your disease is psychogenic” is a non sequitur.
It boils down to the difference between the present indicative and the conditional, I suppose. Between ‘is’ and ‘could be’ or ‘may be’.
“It would be interesting to know how much the Victorian belief in hysterical paralysis derived from fiction, rather than any contemporary empirical analyses. Literary representations reinforcing each other, in other words, without much in the way of reference to the outside world”
Exactly. It’s the suggestion problem that both Charcot and Freud didn’t worry about enough. It’s the self-fulfilling prophecy thing. The Victorians worry about hysterical paralysis, so, whaddya know, there’s a lot of it about. Or there’s some of it about and there’s reported to be a lot of it about. As you say, Miriam – slippery.
“if I’m misrepresenting your views, and you do in fact believe that psychogenic illnesses exist, can you tell us what your criteria would be for recognizing them?”
Of course not! I don’t have any criteria. I’m neither a doctor nor a researcher.”
I’m asking a philosophical question here, not a scientific or medical one. If you do accept the possibility of psychogenic illness, and given you think we know something about medical science, how much negative organic evidence is necessary for you to take the psychogenic possibility seriously?
“I’m not saying no disease can be psychogenic, I’m saying that to say “I don’t know why you’re sick therefore your disease is psychogenic” is a non sequitur.”
I’m glad to hear it OB, and I’m sorry if I misunderstood you, but that’s not what I took away from your complaint about that dodgy definition of hysteria:
“… it inexplicably omits necessary phrases like ‘once thought to be’ and ‘it was thought that’ and ‘but increased knowledge of diseases of the brain and nervous system have rendered such explanations nugatory.’ The phrase ‘for which no physical diagnosis can be found’ ought to read ‘for which no physical diagnosis could be found until researchers discovered organic diseases such as multiple sclerosis and motor neurone disease, and developed a better understanding of the effects of closed-head injuries and spinal injuries’.
As I’ve pointed out, no sensible person is going to attribute a psychogenic aetiology if there’s some plausible organic mechanism for the disorder, and unless a significant and prolonged research effort has failed to identify some credible organic features.
But, since the sum total of medical knowledge is not exactly zero, in the absence of such experimental data, or theoretical support, someone who insists on an organic basis for a given symptom complex in the end owes the rest of us some sort of testable mechanistic hypothesis to support their assertions. Handwaving references to constantly mutating viruses just won’t do.
As I said before, it’s a mistake to conflate the concept of psychogenic illness with Freudian theory. I believe Wittgenstein said that it would take 100 years to undo the damage Freud has done; it seems that in this regard, LW was uncharacteristically optimistic.
“But, since the sum total of medical knowledge is not exactly zero, in the absence of such experimental data, or theoretical support, someone who insists on an organic basis for a given symptom complex in the end owes the rest of us some sort of testable mechanistic hypothesis to support their assertions. Handwaving references to constantly mutating viruses just won’t do.”
On the other hand, it is only within the last 15 odd years that reasonable evidence for a biological component in “mental illnesses” like schizophrenia or autism have emerged.
“no sensible person is going to attribute a psychogenic aetiology if there’s some plausible organic mechanism for the disorder”
Well…to put it one way, that is a very question-begging statement. To put it another way, it’s the non-sensible people I’m talking about.
“But, since the sum total of medical knowledge is not exactly zero, in the absence of such experimental data, or theoretical support, someone who insists on an organic basis for a given symptom complex in the end owes the rest of us some sort of testable mechanistic hypothesis to support their assertions.”
It’s not a question of zero, or of insisting, or of owing, or of the rest of us (who would that be, exactly?), or of assertions. It is, instead, a question of pointing out that a history of attributed psychogenic illness, along with still incomplete understanding of organic illness, suggest a need for caution in jumping to conclusions that current inability to find a physical diagnosis must mean that the disease is hysteria.
The sum total of medical knowledge is not exactly zero, but it’s not 100%, either. You’re surely aware that medical diagnosis is not like plumbing or car repair? That doctors find some cases hard to diagnose? And some impossible? You do know there are some diagnoses that simply include phrases meaning ‘of unknown origin’ and similar?
“On the other hand, it is only within the last 15 odd years that reasonable evidence for a biological component in “mental illnesses” like schizophrenia or autism have emerged.”
More progress has been made in understanding these disorders in the last decade or so, but evidence that schizophrenia, for example, has an organic basis is much older than that. From what I’ve said before, it should be obvious that I’m using “evidence” in the Bayesian sense of information which changes our degree of belief in a hypothesis.
So for example, some evidence that schizophrenia has an organic basis would include identical vs. fraternal twin study data, and the fact that patients improve on certain classes of drugs. This sort of evidence doesn’t tell us what causes the disorder, but it strongly increases the (subjective) probability that it has an organic basis.
We don’t have to know the cause of X to have evidence that X has an organic basis. On the other hand if we havn’t been able to find any such evidence, or if we have evidence to the contrary, shouldn’t someone who claims that X has an organic cause have to justify that claim in a positive way?.
antirealist, I think we’re talking at cross-purposes here. I think you’re translating the idea that psychogenic causes should not be assumed simply because organic causes have not yet been found, into positive claims that an organic cause exists. The two are different. I think it’s a waste of time to keep repeating this.
“The sum total of medical knowledge is not exactly zero, but it’s not 100%, either. You’re surely aware that medical diagnosis is not like plumbing or car repair? That doctors find some cases hard to diagnose? And some impossible? You do know there are some diagnoses that simply include phrases meaning ‘of unknown origin’ and similar?”
OB, I think you’re conflating two quite distinct claims:
1. We don’t know the physical cause of X, and
2. We have no evidence that X has a physical cause
These are not equivalent, and 1 certainly does not imply 2.
Are sarcoidosis or idiopathic thrombocytopenic purpura considered psychogenic? Hardly, because there’s overwhelming evidence of an organic basis, even though we don’t know what it it.
But when we can’t find any evidence of a physical basis for a given set of symptoms, if they clash with current knowledge of anatomy and physiology, and so on, then aren’t we justified in labelling those symptoms psychogenic?
“The phrase ‘for which no physical diagnosis can be found’ ought to read ‘for which no physical diagnosis could be found until researchers discovered organic diseases such as multiple sclerosis and motor neurone disease”
One small historical irony about this remark, which I’d meant to draw attention to before, is that both MS and MND were first properly described by the (infamous?) Dr Jean-Martin Charcot, who recognized them as organic disorders.
“So for example, some evidence that schizophrenia has an organic basis would include identical vs. fraternal twin study data, and the fact that patients improve on certain classes of drugs. This sort of evidence doesn’t tell us what causes the disorder, but it strongly increases the (subjective) probability that it has an organic basis.
We don’t have to know the cause of X to have evidence that X has an organic basis. On the other hand if we havn’t been able to find any such evidence, or if we have evidence to the contrary, shouldn’t someone who claims that X has an organic cause have to justify that claim in a positive way?.”
But you’ve just let psychoactive compounds count as evidence for a physical cause. In that case, I’m pretty sure you could make any psychogenic illness ‘physical’.
I know, about Charcot. He also differentiated MS from Parkinson’s Disease, and named the latter on the basis of Parkinson’s 1817 monograph on paralysis agitans.
I don’t think I am conflating those two claims.
“But when we can’t find any evidence of a physical basis for a given set of symptoms, if they clash with current knowledge of anatomy and physiology, and so on, then aren’t we justified in labelling those symptoms psychogenic?”
Now you’re conflating two things. All I’ve been talking about is the “no physical diagnosis can be found” bit. The clashing with current knowledge is a different subject (and “and so on” is who knows what). Anyway, why is it necessary to “label” those symptoms psychogenic? Why not label them “???”, and for instance attempt to cure or alleviate them by psychological means? But I still don’t see the necessity to label the unknown as the known. I still don’t see why “psychogenic” is an improvement on “don’t know”.
PM: But you’ve just let psychoactive compounds count as evidence for a physical cause. In that case, I’m pretty sure you could make any psychogenic illness ‘physical’.
I know! See how open-minded I am? ;)
My point is that evidence can vary in its “probative value” if you like. If say 5% of patients with hysterical aphonia show a mild improvement on diazepam, that would have a weak effect on my belief that the disorder is psychogenic.
But if 60% of patients show a moderate improvement with some GABAA receptor agonist (I’m making this up), but not with other psychoactive drugs, that evidence is a bit stronger. And if pharmacologists, noticing this effect, produce a more specific GABAA agonist, and that proves even more effective, then that would be quite strong evidence.
It’s the effectiveness of the anti-psychotic drugs, the specificity of their actions, and the class effect that make the schizophrenia evidence strong for me.
OB: Now you’re conflating two things. All I’ve been talking about is the “no physical diagnosis can be found” bit. The clashing with current knowledge is a different subject…
I don’t think so. Again, it’s not a question of not being able to find a physical cause, its not being able to find evidence that there is one. But illness behaviour which would be compatible with a physical cause according to our current knowledge should count as evidence supporting the idea that there is one.
OB: Anyway, why is it necessary to “label” those symptoms psychogenic? Why not label them “???”, and for instance attempt to cure or alleviate them by psychological means?
Labelling a disease doesn’t mean giving it a name, but rather assigning it to a category which has prognostic and therapeutic significance. It’s a pragmatic decision. By attempting to cure or alleviate a set of symptoms by psychological means, you just are ipso facto labelling them as psychogenic. Otherwise what possible rationale could there be for psychological treatment, rather than plasmapheresis, or removal of the nuciform sac?
Until peptic ulcer disease was labelled as an infectious disorder, there was no rationale for treating it with antibiotics. But if someone had done so, and it worked, that would have been evidence supporting an infectious aetiology.
“By attempting to cure or alleviate a set of symptoms by psychological means, you just are ipso facto labelling them as psychogenic.”
Are you? Couldn’t you rather be trying to find out if you can cure them by psychological means, and/or attempting to cure them without being confident that you can? Isn’t it partly diagnostic and also partly hopeful seeing-what-works?
But the distinction seems to me to be a minor one, so perhaps we don’t disagree that much.
Who? Am I supposed to know what you’re talking about?
Sorry OB. Wessely is a psychiatrist and epidemiologist at Kings in London who champions a biopsychosocial approach to phenomena like CFS/ME, Gulf War syndrome, PTSD, multiple chemical sensitivity and the like. Depending one’s source of information, he’s either one of the world’s leading experts on CFS, or a dangerous and pernicious cult leader, “another Roy Meadow” who should be hauled before the GMC for shaming and punishment. Opinions differ, you see.
No doubt they do.
Fortunately, science chugs along, and I have every hope that in twenty or thirty years or so we’ll all agree. You may disagree with me on this, but I personally am glad the biological research continues. I do not consider it a waste of time and resources.
Perhaps in time I myself will even come to agree with you that CFS is entirely psychogenic, if that’s indeed what you’re claiming. It’s a formal possibility.
“Otherwise what possible rationale could there be for psychological treatment, rather than plasmapheresis, or removal of the nuciform sac?”
There is no evidence that psychological treatments in depression work the way people say they do – but they do work.