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Authors of our own misfortune?: The problems with psychogenic explanations for physical illnesses Paperback – September 4, 2012
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About the Author
Angela Kennedy is a social sciences lecturer and researcher at a number of universities in London, and author of numerous articles, papers and books in lay, professional and academic media over a 30 year career. Her academic research interests include: the social stratification, scapegoating and social exclusion of disadvantaged groups, and the effects of these; constructions of moral panics; and the sociology of science and medicine, including manifestations of the 'science wars'.
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Chapter 1 is the [Introduction] and covers the definition of the terms 'psychogenic' and its synonyms, the definition of the terms and purported distinction between 'illness' and 'disease', the existence of psychogenic explanations in the social sciences and humanities, and frames psychogenic explanations for physical illnesses as 'bad science' not 'science as bad'.
Chapter 2 is about [Fallacies in psychogenic explanations] and covers the existence of 'psychogenic explanations by default', the definition and interpretation of various 'signs' and 'symptoms' in medical assessments, the 'black boxing' of proposed psychosomatic mechanisms, and common faulty presumptions that is often part of 'mind over body' ideologies.
Chapter 3 is about [Constructing psychopathology in bodily illness] and covers a key relevant example of a post hoc fallacy i.e. affirming the consequent e.g. responses to illness automatically deemed as causes, the problems defining and measuring 'co-morbid psychiatric disorder', 'neuroticism' and other 'personality disorders', malingering and 'secondary gain', 'hypochondria' and hysteria, and the faulty social stratifications used to support psychogenic explanations.
Chapter 4 is about [Problems of psychogenic explanations in action] and focuses on 'stress', CFS and ME, and the often exaggerated powers which are uncritically attributed to the so-called 'placebo effect' as prime examples of these problems.
Chapter 5 is titled [Mad, bad, and heartsink: constructing 'deviance'] and is about how sick people and their behaviour are commonly characterised or constructed as 'deviant' and 'bad' and 'heartsink' (particularly those with illnesses difficult to diagnose or manage), with advocates or anyone critical of psychogenic explanations also generally characterised as 'bad' by others.
Chapter 6 is titled [Think yourself better] and covers the attitude that all such patients need is cognitive behaviour therapy, discusses issues with evidence based medicine, and the various ways patients are coerced into compliance and compulsion.
Chapter 7 is about the [Consequences of psychogenic explanations] and describes various concerning types of adverse effects which psychogenic explanations have on patients' lives, explains why psychogenic dismissal and construction are bad, and discusses dealing with the stigma arising from psychogenic explanations.
Chapter 8 is the [Conclusion] and raises the issue of whether the direction the DSM is heading towards means 'psychogenic diagnoses for everyone' (that is, much easier for anyone of any illness or disease to receive such a diagnosis), discusses the power struggle that can exist between patients versus doctors, and asks whether society at large finds psychogenic explanations to be seductive and romantic, but finishes with a brief recapitulation of why the reality of psychogenic explanations is not seductive or romantic, but based on fallacious reasoning or harmful ideologies which cause great harm to various aspects of patients' lives.
Kennedy concludes that ideally there needs to be an urgent review of all supposed 'psychosomatic illnesses', with doctors required to account for their diagnoses and take steps to mitigate any harm caused by them, but that all she can realistically hope for is an evolution within the relevant fields to apply more rational skepticism to the notion of psychosomatic illness in general. The problems highlighted in this book are not mere academic curiosities but cause and perpetuate substantial suffering on the world, which does add a strong sense of urgency for anyone affected negatively by psychogenic dismissal in any form.
Although many different aspects are covered in the book, two recurring themes seem to underlie many of these problems, that is, the arbitrary nature of judging what is normal or abnormal (which can be poorly informed by cultural and ideological biases of the judge) with the presumed authority to be able to do so objectively, and the prevailing attitudes about patients, from both professionals and the laity, which are generally pejorative and automatically blame the patient in some way without adequately acknowledging the suffering and struggles endued by the patient or their positive personal strengths.
Highlighted circular arguments and leaps of faith include, the presence of physical symptoms difficult to attribute to a medical diagnosis are taken as evidence (after minimal testing) of a medically unexplained functional condition without underlying pathology, and physical symptoms counting towards psychiatric diagnoses even in the absence of psychopathology but then used as evidence for these symptoms being associated with psychiatric disorder. Exampled hypocrisies on behalf of those promoting psychogenic explanations include a lack of skeptical self-reflection while simultaneously accusing patients of lack of insight and poor self-reflection. Other problems covered include confusing correlation and causation, relying on black boxed psychosomatic mechanisms and/or vague references to psycho-neuro-endo-immunology as the medical equivalent to 'god of the gaps' in philosophy to fill in the gaps in medical knowledge, and clearly privileging the mind over the body despite claiming to have transcended mind-body dualism.
So, what about the possibilities that hypochondria, malingering and secondary gain, faulty or maladaptive beliefs and behaviours, mental factors effecting physical illness beyond unhealthy behaviours, etc, actually do exist and are relevant to human health? Most people will understandably support the general existence of these as 'common sense' realities. Kennedy does not deny that these phenomena exist, but I do feel that this book would have been better with more discussion about the degree of their existence. This however is certainly not a fatal flaw, because although these possibilities are important to explore, investigation cannot proceed properly without first grasping and accounting for the types of problems outlined in this book. Kennedy insists and provides good reasoning for why these issues must be approached with critical evaluation and cannot be taken at face value. These issues have serious implications for patients, have taken on a life of their own as socio-ideological constructs, and are often disconnected from or not adequately based on convincing scientific evidence when applied to specific health problems.
Chronic fatigue syndrome (CFS) is a good example of the problems outlined in this book.
I posted further details about this in a comment on this review below.
This being said, a second and deeper sense of difficulty applies in this book. Kennedy directly challenges both medical doctors and mental health professionals to examine and revise their assumptions about a range of important issues pertaining to so-called "psychogenic" medical symptoms. These are by definition, symptoms of physical disorder or disease that are presumed to be "caused" by the mental state or thinking of the patient. The term "assumed" is highly central here. Kennedy is also challenging professional doctors who may be in emotional denial that what they practice in "psychosomatic" medicine is a dangerous and destructive mythology rather than a consistent or constructive healing art.
Kennedy effectively demolishes an entire branch of current psychiatric practice as codified in the 5th and previous editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. She demonstrates compellingly that there is no basis in science for such diagnoses as "Somatic Symptom Disorder", "Functional Neurological Symptom Disorder (Conversion Disorder)", "Hypochondriasis," or "Munchhausen Syndrome by Proxy". She also sets forth evidence that several presently controversial medical disorders are far better explained as poorly understood medical illness, than they are treated as outgrowths of any emotional or psychogenic process. These medical disorders include Fibromyalgia, Myalgic Encephalomyelitis /Chronic Fatigue Syndrome (ME/CFS), and Irritable Bowel Syndrome (IBS).
Kennedy demonstrates predictable and unnecessary harms that grow from misdiagnosing medical disorders as mental disease entities. Chief among these is the denial of effective medical assessment and treatment to millions of people who are instead written off as "head cases" and then disregarded as reliable reporters of their own medical symptoms and conditions. The careless or frustrated discharge of "difficult" patients who have subtle or unusual medical problems can and already has led to patient deaths. Likewise, among mental health professionals charged with caring for psychosomatic patients, there are no truly effective modalities of treatment. None.
If you are a mental health professional, then you should read this book and ask yourself how many of your patients have been harmed by the fallacies it reveals. If you are a patient who has been referred by a medical doctor for mental health evaluation, or who has been diagnosed with so-called psychogenic symptoms, then you should buy this book and give it to the practitioner who diagnosed you. You may even want to add a note on the flyleaf: "if you can't do better than this, then it's time you looked for an honest line of work!"
Fair Disclosure: I approached this book with a predisposition to accept its premises. I read it to verify that sufficient research was quoted to support those premises. As a social networking site moderator for over 5,000 chronic face pain patients, I have met many who were written off as head cases because their medical doctors didn't recognize what was causing their pain. I have separately published on the connections between psychogenic diagnoses and patient suicides. See "Psychogenic Pain and Iatrogenic Suicide" at [...]
Thus I may have a bias of my own: having seen the damage done to medical patients with rare disorders by psychosomatic medicine, I am convinced that this branch of psychiatry is a complete crock! Practitioners of this mythology should be confronted with the harms they do, and if necessary barred from treating patients until they have been reeducated.