Psychosomatic illness 2b

These psychosomatic illness posts are inspired by a recent book by Suzanne O'Sullivan. I've been waiting for this book for a year, and it was worth the wait. The author, a British neurologist, writes about her experiences with the significant minority of her patients who show up with neurological symptoms, such as seizures, paralysis, or numbness, that turn out to be psychogenic. As a neurologist, she has an impressive array of tools that allow her to rule out organic illness, and as an NHS doctor, she seems to be freer to tell patients the truth and to deny them the tests they ask for than the average U.S. doctor.

Psychosomatic illness is treatable—in fact, “if addressed early enough, many of the manifestations of psychosomatic disorders spontaneously disappear without treatment.” But it's hard to treat--first, because the doctor must consider the possibility of psychosomatic illness, and second, because the patient must accept it. The media's narrative about illness doesn't help. When you read about medically unexplained symptoms, the story is: patient suffers, callous doctors can't help, until finally she finds the one doctor who knows what's going on. Doctors' suggestions that the problem may be psychosomatic are treated as insults directed against the patient. (Examples of this kind of narrative can be found at http://wapo.st/2qxCMm2 and http://bit.ly/2pkcswZ).

A patient in the latter article describes how she resisted suggestions of a psychosomatic illness: “When I found out there was an actual physical thing wrong, it was such a relief, because it meant I wasn't just a hypochondriac or a sissy—it was real." She's happy that she has a physical illness, because having a psychosomatic illness would mean being weak and ridiculous. Because she doesn't want to think of herself as weak or ridiculous, she must have a physical illness. She must reject suggestions of psychosomatic illness and go on doctor-shopping until she gets a diagnosis of physical illness. Of course, it's true that doctors are not perfect diagnosticians, and getting a second or third opinion may be a good idea. But we should consider the possibility of a psychosomatic illness as fairly as we consider the possibility of a physical one. In fact, according to the author, it's more common for a psychosomatic illness to be misdiagnosed as physical than the reverse.

And this harms patients. “The more completely somebody has denied the psychiatric diagnosis and imagined a particular physical paradigm to explain an illness, the more prolonged that illness becomes.”

"The harm that comes from incorrectly labeling a psychosomatic illness as organic, while often underestimated, can be immeasurable. If somebody has been told they have epilepsy and has been allowed to believe that they have a serious, potentially life-threatening brain disease, then this belief alone may be so enmeshed in their mind that it affects their ability to recover...It might lead to toxic unnecessary treatment. It might lead a person to make unnecessary life changes to accommodate the disease. But most importantly, the wrong diagnosis will deny the person the correct treatment. When illness functions as a crutch, it may be difficult to relinquish and something is required to take its place. I have told two patients that they had psychogenic seizures and have come back to the ward a day later to find them sporting crutches. Both patients' seizures went into full remission, but neither could walk unaided for several weeks."

The author is full of compassion and useful advice for how to discuss this subject with patients. "The exact manner in which the diagnosis of a psychosomatic condition is delivered is of pivotal importance. Seizures will often disappear completely immediately after the diagnosis has been given--if it has been given well, that is." Hearing that "The tests are normal. There's nothing wrong with you. Go home" is only going to alienate patients without helping them. Psychogenic illness is something wrong, and something that desperately needs to be treated.

Psychosomatic illness 2

What is psychosomatic illness? Here we arrive at a difficulty, because as soon as I start telling you that X Syndrome is psychosomatic, commenters will jump in to tell me that they know X Syndrome isn't psychosomatic, because their friend had it and she was really suffering and how dare I call her a liar?

This is a stupid objection, but I'm not going to get around to explaining why till later. So, for now, let's focus on less controversial examples of psychosomatic symptoms. In the author's words, “physical manifestations of unhappiness are something we all experience; they are not personality flaws or signs of weakness, they are a part of life.” If you know what it's like to cry, or blush, or tremble, or hyperventilate as a result of emotion, these are all examples of how emotions cause physical changes.

Recall the last time you felt psychosomatic symptoms. Notice that you have a very limited degree of control over these symptoms; even if crying or trembling is very embarrassing for you, you can't make the physical manifestation of an emotion go away any more easily than you can make the emotion go away. This ought not to be news to anyone who feels feelings, but it refutes one common objection to the concept of psychosomatic illness, which is along the lines of "My cousin has chronic fatigue syndrome. I've seen her, and she really suffers! She had to drop out of school and give up her favorite hobby! How can you say she's making it up? Why would she do that to herself?"

Psychosomatic illness indeed causes people pain, and sufferers are not lying or consciously making themselves suffer. It's not a pretend illness; it's an illness. As to why a person would do that to themselves, well, read Freud. Or think back to times when you've wanted to punch a wall, or start an argument, or drink till you pass out, or run till you collapse. Our psyches choose one kind of suffering to avoid another. I rate this objection: Completely Wrong.

Psychosomatic illness 1

Psychosomatic illness is one of the greatest causes of suffering in our society--one that is stigmatized, understudied, underdiagnosed, and undertreated when it is diagnosed. If you've never had a psychosomatic illness yourself, you likely know someone who has. On an average day perhaps as many as a third of people who go to see their general practitioner have symptoms that are deemed medically unexplained (quotes are in italics). For most of us, these symptoms are fairly mild: headache, upset stomach, fatigue. For some, the symptoms become crippling and cinematic: paralysis, seizures, inability to talk, loss of memory.

Almost any symptom we can imagine can become real when we are in distress--tremor, fatigue, speech impairments, numbness. Anything. Almost any function of the body can be affected in almost any way. One day a woman loses speech entirely and the next day she speaks in the voice of a child. A girl feels a lump in her throat and becomes convinced she cannot swallow. Eyes close involuntarily and no amount of coaxing or prising will open them. A boy repeatedly drops the ground; every time he stands, he falls. History has seen every one of these things described. [From a 1764 author]: The colours of the chameleon are not more numerous and inconstant than the varieties of the hypochondriac and hysteric disease.

And yet, many observers as well as sufferers reject the concept of psychogenic illness. I hope that this series of posts will elucidate what psychosomatic is, refute some common objections to the post, and give you an idea of when you should consider the possibility that you have it.

Packingham and censorship of sex offenders

Let's talk about Packingham v. North Carolina. May states constitutionally ban convicted sex offenders from using social media? Some points that came up:

• Social media is an important part of modern life. The President uses Twitter to convey breaking news--this law would ban sex offenders from reading the President's Twitter feed. Isn't that excluding sex offenders from fully participating in our polity as informed citizens? Who's going to tell Packingham about the latest dead celebrity?
• On the other hand, there's a lot of precedent for denying people rights after they have been duly convicted of crimes. Going to prison means losing many rights. Not only that, after release you may face indefinite or lifetime loss of certain rights, like the right to vote or right to bear arms. You can lose the latter after only a misdemeanor conviction or even a restraining order! So if we don't sympathize with the guy who slaps his girlfriend and permanently loses his Second Amendment rights, why should we sympathize with the sex offender who loses access to Facebook?
• It's legally irrelevant, but since I brought up sympathy, let's have a moment of sympathy for the "sex offender" in this case, who was put on the registry after having sex with a 13-year-old when he was 21, fifteen years ago. A bad decision, but not bad enough to justify being on a sex offender registry.
• A big reason why Packingham won (spoiler) was the overbreadth of the law. It banned "gaining access to" social-networking sites that allow minors, no matter what you do on those sites, even if you have zero contact with minors, and even if you never post any comment. (Packingham got in trouble after a Facebook post in which he attributed getting out of a couple of traffic tickets to being specially favored by Jesus. I'm no theologian, but I would think once you're a registered sex offender you'd give up on the idea of being favored by God.)
• The law also categorized any site as a "social-networking site" if it allows users to comment and does not ban under-18 users. So not just what you or I would think of as social-networking sites, but most news sites, blogs, job sites, and many commercial sites like Amazon that allow user reviews.
• So a law meant to prevent sex predators from seducing children online ends up banning people from buying shoes on Zappos, looking for apartments on Craigslist, or reading WashingtonPost.com. If the person who wrote the law had drafted more cautiously, this law would have survived as a narrowly tailored "don't contact strange kids online" rule. Why don't people hire me to write these laws? As it is, the law was struck down as an unconstitutional restriction on speech.  

Don't use the courts to force people to like you

Social approval! We all want it. And we're never going to get it--at least, not as much as we want. Whether the people around you approve of you is not within your control. Well, some of it is--you can take some voluntary actions to improve your chances of approval. Being nice and tipping and taking showers helps. But that will never guarantee you get the approval you want.

Why not? Part of it is pure luck--or “privilege,” grudgingly. Part of it is the “you can't please everyone” effect. Being upper-class is generally good, but not if you want to fit in in a lower-class environment. Some people resent immigrants; others think Americans are dumb. Some people will hate you for being black, and others for being white. You can be fat-shamed or skinny-shamed. So, fundamentally, we have to live in a world in which, no matter who you are, some people will hate you for no good reason. A woman has to navigate a world with misogynists and rapists in it. An atheist has to accept that many people think he's going to burn in hell. And gay people have to live with the knowledge that many of their neighbors disapprove of their sexual and romantic relationships. For the person who finds these facts upsetting, I recommend Agent Cooper's mantra.

FBI Agent Roger Hardy: They're liable to extradite you for murder and drug trafficking.

Special Agent Dale Cooper: These are things I cannot control.

This is my problem with the current gay rights movement. As a libertine and libertarian, I have of course been strongly in favor of gay rights as long as I can remember. When gay marriage was banned, and, earlier, when gay sex was illegal, there was a crying need to fight so that gay people can get what they deserve.

But now? Every time I read about a new gay rights case, it's, well, bullying. Suing the small business owner who refuses to sell flowers or cake or custom-printed T-shirts for gay weddings or gay causes. These are not cases about getting gay people what they deserve-- the same privileges and rights the rest of us enjoy. This is using the courts to force the illusion of social approval.

Not even the plaintiffs claim that any person has actually been damaged in these cases. One litigant in a right-to-wedding-flowers case claimed that his actual damages were some $17, or the cost of the gas he burned when he had to drive to a different florist. In another case involving a transgender high school student, the biologically male student wanted to use the girls' locker room; the school wanted him to use the boys' room, and offered the obvious compromise; a private changing room for this student. The offer was rejected--proving, beyond a doubt, that the transgender bathroom controversy is not about providing safe and decent bathroom facilities for transgender people. It's about forcing society to accept the transgender theory of gender. This is completely wrong. Partly, of course, I think it's wrong because my concept of gender is different. But it would be wrong to use the courts to force people to accept my gender theory too! I just have to live in a world in which most people are terribly, terribly, wrong, and, rather than being something the courts ought to correct, this seems like the human condition.

Litigating for social approval is not what the courts are there for. Social approval is not something gay or transgender people deserve, because desserts don't make sense in this context, because social approval is inherently arbitrary.

I wonder if the gay rights advocates agree with me on this point. Is it that they think of approval as something that you are entitled to, if you do x and y? In my life, I've gone from being one of the most stigmatized, powerless and low-status people in our society, to now being reasonably successful and respected. From having to ask dumb people for permission to go to the bathroom to having a job that largely consists of telling smart people what to do. And yet, I feel like the same person. It creates some cognitive dissonance that I've never really known how to communicate. But, other people have not had this experience. If you've always had people approve of you if you did the “right” thing, I imagine you might come to think of approval as something you “deserve.”

Another possibility is that gay rights advocates think of these cases not as means of redressing specific wrongs done to the plaintiffs, but rather as a means of shifting popular opinion. So it's not about fighting for what someone deserves, but rather conducting something of a morality play in which the state of the law is merely a public relations tool.

I would be interested in hearing your opinion, especially if you agree with these gay rights cases. Do you think social approval is something that people deserve? Or do you think these cases are a PR tool? Or do you think our disagreement resides somewhere else?

Gay conversion therapy

This is an interesting issue that I expect to neatly divide the liberals from the libertarians. Should "conversion therapy," a.k.a. therapy intended to make gay people straight, be banned?

Arguments against it:

• It's unpopular with the mob. "In two different national polls, more than 60 percent of Americans indicated that they believe conversion therapy doesn’t work." Who cares?
  
• The American Psychological Association says it's not backed by evidence. But this would support banning pretty much all psychotherapy, not to mention alternative medicine. Psychiatry is not a science, and it's common to see that any given treatment works for some and not others.
  
• Part of the reason there's no evidence base is that it's hard to verify whether someone who says he is straight is straight. I don't see a way around this, other than a longer follow-up period.
  
• Homosexuality isn't a "mental illness." But whether something counts as a mental illness or not is a political decision. People should be able to seek treatment for whatever is troubling them, regardless of whether it's in the DSM.
  
• Conversion therapy sometimes makes people feel worse. Again, no different from any other therapy.
  
• Children should not be given conversion therapy because they don't have the capacity to freely consent to it. I'm pretty sympathetic to the argument that children shouldn't be brainwashed. But why is brainwashing bad when applied to “correct” homosexuality, and not when applied to “correct” drug use, heterosexual sex, bad grades or any of the other sins for which children are sent to therapy?
  

Argument for:

• Boils down to the basic libertarian argument that people ought to be able to do what they want to with their own lives. Like it or not, some people don't want to be gay and are desperate for a way to avoid it. Cultural liberals may think it's laughable or sad for a gay man to marry a woman and call himself straight. But is it any more absurd than some of the weird sex liberals get up to?
  

How to make a phone call

The first step in making a phone call is putting the call on your schedule. Some people might do it immediately, but you can't risk calling at the wrong time. Maybe you haven't gotten enough sleep or you are in a bad mood or something. You also have to wait for a time when the person will be at work, decreasing the likelihood that he will answer. Maybe if you give it some thought, you can get what you want without a phone call. Really a phone call would never be necessary if not for the stupidity of others. Wait a few weeks or months.

At long last, when it's the right time, find the strength to look up the number. Then, go to the bathroom. Consider your shampoo collection. Which shampoo should you use next? The "rosemary mint" from the New Orleans hotel, the "aloe vera" from Wisconsin, or the "sugared citrus" from Minneapolis? The rosemary mint looks most expensive, but Minneapolis is clearly better than New Orleans.

If you decide you like the rosemary mint best, should you use it last, so that you have the pleasure of anticipating the best? Save the best for last, as they say. Or should you use it first, because you might die before you use them all? Seize the day, they also say. You wouldn't want to die without taking advantage of the best shampoo available to you. You will probably find this decision impossible, but spend some time on it anyway.

When you have lost interest in the shampoo, put the number into your phone. Stare at it, conscious you could still turn back. Then press the call button. Count the rings, forgetting to breathe. If it rings at least five times, it'll probably go to voicemail. It does. You will have planned out precisely what to say on the voicemail in advance, so this is the easy part.

Hang up, and get as much satisfaction as you can out of crossing out the to-do list item. Then it will occur to you that getting a return call is a real risk. Remember how the person's voicemail message said "I will call you back"— so decisive. You're screwed.

Try to distract yourself with an easier task. But how can you concentrate when the phone could ring at any moment? It sits beside you, like a viper ready to strike. You have made a phone call, but it made nothing better. Someday, you will have to talk to a stranger.