SKEWED:
Psychiatric
hegemony and the manufacture of mental illness in
Multiple Chemical
Sensitivity, Gulf War Syndrome,
Myalgic Encephalomyelitis and Chronic Fatigue
Syndrome.
Martin J. Walker
ISBN 0-9519646-4-X
Published by Slingshot Publications, BM
Box 8314, London WC1N 3XX, England
Cover price £12.00
Note from publisher: Cheques or postal
orders must be sent with orders to Slingshot — no books can be sent out without
payment. Campaigning groups who wish to raise money by selling the book, can
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conference/launch is planned for December 2003 — for an invitation, contact
Slingshot.
Foreword
Per Dalen, MD, PhD, Associate
Professor of Psychiatry, University of Gothenburg, Sweden
Medical culture is obsessed with mechanisms of disease, but actual causes
are not a favourite topic. We don't know enough about causes to inspire the lay
public and ourselves with confidence in our science by discussing them. Our
lack of success in preventing many important diseases is of course largely due
to ignorance. It is not uncommon for a medical scientist to mention an unsolved
problem in terms like "the exact causes are not yet known, but…" The
discussion is then usually moved to the safer ground of mechanisms.
One tacit assumption is that we should first of all learn as much as
possible about the many biochemical and physiological mechanisms that may be
involved in the production of symptoms, autoimmunity for instance, or changes
in neurotransmitter levels. With a more complete biological 'Meccano', it
should be possible to build more and more comprehensive models of how various
diseases develop. Will this automatically lead to causal understanding at the
level where prevention becomes possible? Not necessarily, I am afraid. New
causal knowledge may more often be found serendipitously and in other more
direct and less time consuming ways than this inching along in the search for
mechanisms. However, such a direct approach is usually not encouraged by the scientific
community.
There is an additional reason why mechanisms are important in medicine.
When we draw the line between science and non-science in the health field, we
usually exclude procedures and theories that cannot be understood in terms of
accepted mechanisms. Homeopathy is a case in point. It doesn't really matter if
it works in practice; its theory is utterly at odds with conventional medical
thought. Any positive results in patients are simply explained as placebo
effects. In this way knowledge of mechanisms becomes indispensable as a badge
of scientific authority.
My training in psychiatry started in the late 1950s, when neuroleptics
and antidepressants were already available and the specialty was showing more
scientific promise than ever before. Hysteria was something that neurologists
encountered. Experienced psychiatists would tell stories of supposedly
hysterical patients who had been referred back to their neurologists or
internists without a psychiatric diagnosis, but with the suggestion that
further investigation might be indicated — whereupon a brain tumour or some
other serious illness was revealed. The average psychiatrist was then (and
still is) fully occupied with patients whose histories and symptoms were
predominantly psychiatric. The idea that large numbers of patients in general
practice might need our attention for "medically unexplained
symptoms"' freely labelled as somatized, was simply unheard of.
'Somatization' is not a novel word. The oldest entry in the Oxford
English Dictionary is from 1925 and shows that the origin of the word is in
psychoanalysis: "conversion of emotional states into physical
symptoms." This is of course a sanitized version of the hysteria concept,
a psychiatric diagnosis. Sigmund Freud put forward a number of psychological
postulates styled as mechanisms that seeped into popular culture but were less
successful in the medical field. Psychoanalysis is perhaps somewhat too
speculative to mix well with ideas based on biology. Medicine has a kind of
vigilance or "immune" system which resists intrusion of thoughts that
fall short of a slightly pedantic standard of scientific credibility. The
grapevine telegraph keeps us alert and updated. Inevitably though, there is no
natural or manmade vigilance without blind spots.
Emotional states can give rise to bodily symptoms; this is a matter of everyday
experience. It is, however, deceptively easy to exaggerate the importance of
this mind-body connection. The necessary question therefore becomes what, and
how much can be reliably attributed to which emotional causes and for how long.
This can only be answered from experience and common sense, since the actual
mechanisms are very poorly understood and systematic clinical evidence is
scarce.
A generation ago physicians usually trusted their own clinical
judgements, but in recent years the notion of "evidence based"
medicine has altered this. We are now supposed to look for evidence, preferably
statistical evidence, in the current literature. In some areas, such as
somatization, there is simply no solid evidence, and yet the grapevine is
silent about this. A vacuum is created where other forms of persuasion can find
their way to the medical profession.
It is interesting that another blind spot can be found in the area of
placebo. Somatization and placebo are like the two sides of a coin. Both are
believed to possess great power, the one of causing disease, the other of
restoring health, Their mechanisms of operation are essentially unknown, and
systematic studies have in fact yielded little or no evidence in clinical
situations.
There is no denying it; medicine uses a double standard in relation to
scientific evidence. The placebo has been an integral part of our medical
culture since the 1950s. Somatization gained prominence relatively recently.
Scientific ideas normally have an interesting history, including a genealogy
and a record of arguments pro and con. Important ideas rarely enter the scene
fully fledged and unruffled by controversies, but somatization was presented
even without a reference to psychoanalysis.
Today we are sometimes told that somatization is the disease process to
consider when physicians fail to explain the symptoms of the patient. The
rather too flattering implication would be that medical science can now explain
so many things that most of the remaining problems can be bundled together
under a collective psychiatric label without further investigation. The truth,
however, as we have seen, is that causal understanding is poorly developed.
Explaining symptoms means something else here.
When an officially accepted diagnosis has been found in a given case, for
example, multiple sclerosis, the principal symptoms of the patient are seen as
constituent parts of a familiar picture, and predictions can be made about
prognosis, possible treatments can be chosen, et cetera. The physician is
satisfied by this result, even though the cause of multiple sclerosis remains
unknown, prevention is impossible, and treatments do not offer much hope of
permanent recovery.
An accepted diagnosis is not always enough, however. Recurrent or chronic
low back pain is sometimes mentioned as a possible form of somatization. The
reason for this is that most cases show no structural changes upon thorough
investigation. Orthopaedic surgeons see innumerable patients with this very
common affliction, and treatment results are poor. So why not call this a
psychiatric problem? To my knowledge, psychiatry has never been officially or
openly asked whether it is acceptable to use, or abuse, the concepts and tools
of this specialty in new and unexpected ways. Psychiatrists tend to be hungry
for acceptance by their non-psychiatric colleagues, and have not so far
protested very audibly against what is going on under the label of
somatization. GPs aided by psychologists skilled in cognitive behaviour therapy
can apparently do the actual work with the patients.
A major problem with the somatization approach is that its proponents
take for granted that the causes of all those illnesses relabelled as psychiatric
are psychological. In modern psychiatry the trend has long been in the opposite
direction, away from the dogmatism once inspired by psychoanalysis. Classical
psychiatric illnesses have unknown causes just as often as do somatic
illnesses, and wholesale psychological explanations are increasingly a thing of
the past.
For some years now I have been convinced that the concept of somatization
is being exploited for reasons that are only partly transparent. Scientifically
there is no basis for the remarkable expansion of this field. The lives of
large numbers of patients are touched and often made more difficult by what is
going on. Psychiatry is apparently being abused, and it is, of course, very
important to find out more about the background in order to do something about
it. This is an area where concerned citizens have already begun to organise.
In Skewed, Martin Walker investigates the vested interests involved in
the problem of somatization and "unexplained illness". On reading the
manuscript, I found that viewing this apparently medical question from a
sociological perspective gave me a new insight into this growing area of
ostensibly psychiatric disorders. Readers who are not yet familiar with the
tragic erosion of the truth-seeking scientific spirit in medical research will,
I hope, also find this book an excellent introduction to these problems.
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