THE MEDICALISATION OF MISFORTUNE
With comments by Dr. Trevor Jordan, Dr. Gerry Kent and Dr. David Tombs
This paper first appeared in volume 5 of the 'Skeptical Intelligencer', 2002.
It is often noted how nowadays there seems to be a growing tendency for personal difficulties, disappointments, frustrations and misfortunes in everyday life to be construed as the business of experts who are equipped with the knowledge and skills to diagnose what is wrong, how the problems came about, and how they can be cured or at least ameliorated. One way of describing this process is to talk about the increasing 'pathologising' or 'medicalising' of difficulties and misfortunes and the progressive 'colonising' of these areas of life by presumed experts from the healing industries. Such statements are usually made by people who bemoan this trend and would like something to be done to reverse it.
For example, in a recent article in the Sunday Times ('Stop taking the alternative medicine') GP Michael Fitzpatrick wrote:
The redefinition of illness as disease has become the dominant medical response to unexplained physical symptoms which are given labels such as ME, fibromyalgia, irritable bowel syndrome. The expansion of psychiatric diagnoses, from depression and anxiety to attention deficit disorder, hyperactivity disorder and post-traumatic stress disorder, now takes in a substantial section of the population. The effect of these labels is often to intensify and prolong the incapacity.
Dr. Fitzpatrick mentions post-traumatic stress disorder and I shall return to this shortly. Another common target for critics who are concerned about this trend for 'over-pathologising' is 'stress'. This term is very commonly used in a very broad and ill-defined way, often to cover a wide range of states of mind and body in which the person regularly experiences unpleasant feelings such as anxiety, low mood, tiredness, and irritability, apparently due to the demands of his or her daily life. Nowadays people may consult experts in stress management and receive counselling and therapy. Large employers frequently arrange stress management courses for their staff, and books and audio and video cassette tapes on stress management proliferate. It is not incorrect therefore to speak of the 'stress management industry'.
Some critics, such as Dr. Fitzpatrick, feel that all of this, far from being helpful, is exploitative; it encourages people to regard themselves as victims in need of the ministrations of experts who know much more about their problems than they do. Critics also question whether the experts do indeed have anything more to offer than their clients can achieve for themselves.
All of this may indeed by the case, but it is not the purpose here to decide one way or the other. What is clear from the analysis presented earlier in this journal (and on this website: 'Healing and Therapy in the Age of Mass Affluence') is that this process is not just something that has been foisted on the unsuspecting public by a self-interested faction. It is an inevitable development in a society in which there is economic freedom, increasing affluence, and the relentless accumulation of knowledge. It reflects not just the self-interest of those who promote this approach to life's difficulties (and whatever specialised knowledge and expertise they posses). It also reflects the ever-expanding range and diversity of what life has to offer, the corresponding increase in the expectations of people to gain and hold onto the benefits of these, and their belief that they are entitled to do so and that impediments to these, even those as vague as general malaise and debility, should be explained and alleviated. As was indicated in my earlier article, this is inevitably associated with the increasing complexity of the problems people face in their lives and the corresponding expansion and increasing specialisation of the range of diagnostic categories in medicine (in its broadest sense orthodox medicine, allied professions, alternative medicine and commercial, over-the-counter medicines).
This is not just a reflection of the constant progress in understanding human physical and psychological illness and difficulty, since, for example, alternative medicine manages to flourish, expand and diversify uninformed by such progress (likewise, to some extent, commercial medicine). It is also, as I have said, associated with increasing affluence and opportunity. However, it is still inevitable that genuine advances in knowledge and its application will lead to 'medicalisation' of everyday problems. There is a scientific literature on 'stress' and scientifically evaluated ways of reducing or avoiding stress. Likewise 'post-traumatic stress disorder': the scientific study of human beings who have experienced life-threatening events such as a road traffic accident cannot help but reveal that they commonly report a constellation of very distressing symptoms and problems that other people do not, and that there are ways in which these can be eased or eliminated.
Yet we must still be aware of the principle of interdependence expounded in my previously-mentioned paper; this advance in human knowledge does not occur in isolation from the rest of society. I have already rehearsed the arguments for this but it is worth reminding the reader how, for example, psychiatric diagnoses have over the years rapidly expanded and become more specialised, and that the common criteria of most of the mental and personality disorders in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) is 'The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning'. (Diagnoses according to DSM-IV and the International Classification of Diseases of the World Health Organisation typically differ from those in general medicine (except in some instances such as, interestingly enough, irritable bowel syndrome) in that they rely, not on the identification of some underlying pathology that gives rise to the symptoms, but on a tally of the symptoms themselves. Hence a person may be suffering from psychological difficulties such as poor sleep, and nightmares and flashbacks of a traumatic event, yet not be diagnosed with a psychiatric disorder (e.g. post-traumatic stress disorder) because the threshold for the symptom tally is not reached.)
There is no stopping the medical profession, of which Dr. Fitzpatrick is a part, allied professions (conventional and unconventional), and the commercial medical sector each from laying claim to being the authentic agents whereby life's vicissitudes, annoyances disappointments and difficulties can be understood and remedied. In the case of orthodox medicine and psychiatry we might challenge the scientific legitimacy of diagnoses such as 'intermittent explosive disorder' and 'oppositional defiant disorder', but if they are, as they appear to be, based on carefully conducted surveys and analyses of human behaviour, what else can we do?
(In fairness I do not wish to exaggerate the significance of the expansion of psychiatric diagnoses which, in accordance with the principle of interdependence, is probably associated with the need to classify 'disorders' for the purposes of the funding of psychiatric treatment by American medical insurance companies and for legal and forensic purposes. In general psychiatry, the position is much simpler, as will be seen below).
A final point to make is that those who refer to the over-medicalisation of problems presumably have some criteria in mind as to what constitutes a problem for medicine and what does not. I suspect that an implicit criterion is whether there happens to be any medicine that can alleviate the problem. For example, we may complain that the medical diagnosis and treatment of daytime 'stress' is a deplorable modern development, yet generations of patients have been diagnosed with and effectively treated for night-time stress, namely insomnia, purely because doctors have always known about the hypnotic effects of certain substances.
Consultation with Three Professionals
To further this discussion I approached three professionals for their opinions.
Dr. Trevor Jordan
Dr. Trevor Jordan is an ASKE member and a retired general practitioner.
As a GP did you find that most of your patients' problems were well handled by the 'medical model' (examination of symptoms and signs, provisional diagnosis, tests, final diagnosis, prognosis and treatment)? How much did you notice the 'placebo' effect?
As a medical student I was assigned to Dr. RH, a local GP, for experience of general practice. One day we visited a young boy who complained of a sore throat, a cough and a fever. Examination revealed very enlarged lymph glands in his neck, a heavy white coating on his tonsils and a fever. Dr. RH diagnosed 'acute tonsillitis' and issued a prescription for penicillin syrup. We left, advising the boy's mother to 'call the surgery if he isn't better in two or three days.'I then asked Dr. Jordan for his comments on the quote from the 'Sunday Times' article by Michael Fitzpatrick given earlier in this article.
Outside I complained: 'Shouldn't we take seriously the alternative diagnoses of Hodgkin's disease, tuberculosis (more prevalent then than now) and so on? At the very least shouldn't we do laboratory tests on the tonsillar exudate to determine if it really was bacterial and not the probably more common viral tonsillitis for which penicillin was useless?'
Dr. RH explained: 'An acute infection was much the most likely diagnosis. Hospital tests, biopsies and X-rays were time-consuming and expensive. In two or three days the child would either be better, in which case further tests would be unnecessary: or he would not be better in which case the other less common diagnoses could still be considered and the tests ordered. Delaying the ordering of the tests for two or three days would make no discernible difference to the outcome. What was more, the child and his mother had not been exposed to the fears and anxieties which would certainly arise had the more serious but much, much less likely diagnoses been discussed at the outset.'
'But what about the antibiotic? To use your logic, the probable diagnosis is a viral infection, so your penicillin is more than likely unnecessary and will make no difference.'
'Yes,' replied my trainer, 'but it buys us the two or three days during which any self-limiting viral illness will begin to subside. Mother will happily nurse the boy for two or three days 'while the antibiotics are getting to work' but will call us back tomorrow if we don't provide him with what she perceives as treatment!'
This scenario is repeated time after time after time in general practice. It is unscientific. It does not follow the strict 'medical model.' It depends on the experience of the physician (I was later to learn that there are other telltale signs which might lead to an immediate suspicion of the other diagnoses) and it certainly 'pleased' the patient and his mother; so to that extent it relied in part on the 'placebo' effect.
It can be argued that this has much in common with alternative medicine! There is a lack of scientific rigour; the evidence is anecdotal; it relies on 'personal experience' and there are no double-blind controlled trials; the substance used is known not to be effective in most cases; there is a conscious effort to 'please' the patient; and it 'works' because there is a strong probability that the illness will be self-limiting. But its elements are amenable to reasonable rational explanation, a characteristic lacking alternative medicine.
Yes, yes and yes! The situation is inevitably more complicated than this, and it touches on disciplines other than medicine, but Fitzpatrick's premises are basically sound. Some years ago a survey suggested that we all experience an average of ten 'potentially significant symptoms' in any two-week period. Part of the enormous pressure on general practice these days is undoubtedly due to the increasing frequency with which these 'symptoms' are presented to the primary care doctor for advice. We are less and less willing to put up with our aches and pains, and the information explosion means that each is invested with unwarranted significance. Every headache becomes the warning sign of a brain tumour, every cough the early sign of lung cancer, every dyspeptic twinge is a 'peptic ulcer' and so on. (Potentially, if every symptom were to result in a surgery visit, the workload would increase from the current 7,500 consultations per GP per year to around 650,000!)
But we are taught from an early age now that we 'don't need' to suffer even the smallest discomfort and therefore 'something must be done, doctor.' But, as I said earlier, to refuse the patient medicine or a pill often provokes him or her into returning until a prescription is finally given. In self-defence the GP will therefore often comply with the assumption that there is a pill for every ill and prescribe inappropriately on the first visit. The 'illness' behaviour is now reinforced on both sides.
Additionally, the medical model specifically disapproves of the treatment of symptoms, and undoubtedly patients prefer to believe that their suffering is legitimate. So common clusters of symptoms tend to attract labels. These labels elevate the symptoms to the status of a 'known or named illness' and legitimise both the doctor's behaviour in offering treatment and the patient's behaviour in seeking it. It is socially and personally more acceptable, after all, to take time away from work because one has, say, 'Jackson's syndrome' than because one has nausea, headache and abdominal cramps which the unenlightened or unsympathetic might otherwise be tempted to call a 'hangover.'
This is true for physical symptoms, but along with our 'right' not to suffer physically we have also invented the 'right' not to be unhappy. But that isn't serious enough to warrant treatment or a sick note so we must suffer from 'depression' or suffer from 'an affective disorder' or 'seasonal affective disorder.' People with the first two are given pills and those with the third are prescribed sunlamps, in my view too easily and too frequently just as thirty years ago we too readily prescribed Librium and Valium, the panaceas of their day for all unhappiness.
Increasingly many of these 'medical treatments' are being seen for what they often are: ineffective, and sometimes even toxic the cure is more troublesome than the disease. However there is an army of people who will promise the same reward freedom from all discomfort and guilt by alternative methods. Crystals, magnets, supplementary minerals, channelling of energy fields, psychic healing, homeopathy, Reiki, rebirthing: any and every theory is employed in one 'therapy' or another.
We should not be surprised that their practitioners consistently refuse to put them up for validation by independent scientists: it is their livelihood, after all. But would that more people had the common sense of a young mother whom I met with her happy, inquisitive, energetic two-year old wriggling in her arms. "Oh, all the other kids round here are hyperactive and on pills," she said, "but this one he's just a little bugger!"
There's no pill for that complaint! Yet.
Comments by Dr. Gerry Kent and Dr. David Tombs
I also asked Dr Gerry Kent, for his opinion on Dr. Fitzpatrick's comments. Dr. Kent is a clinical psychologist at the University of Sheffield, who specialises in health psychology and works at a pain clinic with patients diagnosed with, amongst other things, fibromyalgia and irritable bowel syndrome.
In Dr. Kent's opinion, it is helpful sometimes for patients to have a label for their problem as it may remove the possibility of their feeling stigmatised by complaining of symptoms that are not yet given a diagnosis and makes it easier to deal with people's reactions to their symptoms. Dr. Kent also suggested that this might be of more help in the short than in the long term. In the case of long-term symptoms that are disabling, a label may encourage the individual to feel that he or she does not have any responsibility for what can be done for him or her the problem is out of his or her control. However, Dr. Kent admitted that this was only his impression: he knew of no evidence to support it and, if true, he was unsure to what extent it occurs. Dr. Kent certainly felt that Dr. Fitzpatrick should back up his own assertion with some evidence.
The last view was echoed by Dr. David Tombs, consultant forensic psychiatrist, (now at Rampton Secure Hospital), but he admitted that Dr. Fitzpatrick may be right. In his opinion, what is different now from the past is the labels that are used. He does not believe that there is any tendency for people to have become more neurotic, but people seem less willing to tolerate stress or distress and more people go to their GPs on account of this. He cited the weakening of the family unit as one possible cause of this. Most people consulting their GP in this way do not need to see a psychiatrist; GPs are able to provide safe medication if necessary or refer patients for psychological therapy, such as cognitive behaviour therapy, the efficacy of which has been demonstrated.
I asked Dr. Tombs about psychiatric diagnoses and he agreed that, strictly as presented in DSM-IV and ICD-10 (see earlier), these rely on the 'totting up' of established criteria. This method is less used in organic medicine. Dr. Tombs acknowledged the rapid expansion of psychiatric diagnoses but, consistent with my own impression, pointed out that the details of many of these are unfamiliar to most psychiatrists. He estimated that a general psychiatrist would probably consult DSM-IV or ICD-10 about 6 times a year. He made the point that, so far as diagnoses are concerned, there are probably a relatively small number of major divisions, and the same goes for medication. The most significant division for psychiatry is between psychosis and the rest i.e. neurosis and personality difficulty or disorder, the latter being subsumed under Axis II of DSM-IV, Axis I being mental disorders.
Attitudes of the three professional to alternative medicine
I asked Dr. Jordan the following:
Have you ever as a medical doctor treated someone with what you would consider to be alternative medicine? Or have you referred or recommended your patients to practitioners of alternative medicine?
You're right to qualify the term 'alternative medicine.' I use it to mean any method that entails 'explanations' of the causes of disease and of the curative nature of the remedy, which are no more than blunt assertions, and a refusal on the part of the practitioner to submit these assertions to any form of scientific enquiry. That said, I have never practised alternative medicine. (I have practised hypnosis, but ethical practitioners of that discipline are not averse to scientific enquiry and so I do not subsume it under the 'alternative' label, although many of my colleagues regarded it as 'fringe medicine' at best!) And I have never referred anyone to alternative practitioners. Indeed I have had occasion actively to dissuade patients from attending one such person. Over a period of four or five years he went from the universal diagnosis of mercury poisoning (every patient he saw was advised to have their mercury amalgam dental fillings replaced) to the equally universal diagnosis of 'intestinal candidiasis' (every patient he saw in this phase suffered from an 'allergy' to the 'thrush organisms we all carry in our gut') and thence to universal mineral deficiency (every patient had his or her samples 'sent to America' for analysis, which always showed mineral deficiencies requiring dietary supplements). On any level this is plainly nonsense and it would be unethical to recommend anyone to such a practice. Of course there are many well-meaning and undoubtedly ethical practitioners of alternative medicine: not all are outright charlatans like the example I gave above. But until their various cures and remedies are shown to be statistically more effective that conventional medicine, which includes the time-honoured method of allowing nature to take its course, as with any self-limiting disease, they cannot be a referral option for any practitioner of modern orthodox medicine.
Dr. Kent does not have a particular view on alternative medicine and confessed not to have studied much about it. However he did draw my attention to 'regret theory'. This is the idea that an important motive for choosing an unconventional treatment is to avoid 'regret': the patient tries it 'just in case' and later does not feel any self-recrimination for not having done so.
Dr. Tombs confessed that he was not very knowledgeable about alternative medicine (he understood that acupuncture may be useful for addictions and homeopathy as a placebo) but believed this would be of benefit to people with 'fear-based symptoms'