I just discovered antidisestablishmentarismque. The author takes to the underlying assumptions within various research reports in the NY Times andgnereally does a good job of skewering them.
I found this New York Times article deeply offensive. Here’s the lede:People with a long history of medically unexplained symptoms — aches, pains, fatigue, dizziness and other complaints for which doctors can find no physical cause — might finally find relief.Literal meaning: Hey, all you who people who modern medicine can’t help, we might be able to help you.Sounds pretty promising, right? Unfortunately the next paragraph blows that out of the water:Two new studies by researchers who specialize in the baffling condition called somatization syndrome, estimated to affect up to 3 percent of adults, suggest that the quest for a physical explanation may take on a destructive life of its own. Instead, those with the syndrome should focus on practical strategies to regain normal function and relieve symptoms, the researchers say.Wow. That is poorly written. Let’s dissect that nonsense. First, they make up a name, somatization syndrome, as a catch-all for everything that doctor’s can’t seem to diagnose. That’s unhelpful.Then the article obliquely says that nothing is wrong with these people; it’s all in their head. Well, golly-gee, if doctor’s can’t figure out what’s wrong with you what does that leave? Nothing. You must be fine; you’re just crazy. It can’t possibly be the doctor or modern medicine that’s at fault. No sir-ee, if doctor’s can’t diagnose it that means it doesn’t exist.
Now the first issue is that this is a press report. The real paper is here. — or at least the first one. Like many papers in the field, the issues with it ar:
- It is underpowered.
- They use standard scales for somatization.
- They are matching poorly. This really is a survey. A better design would be a case control paper.
Therefore… the conclusions of this paper need to be taken very, very lightly. To a certain extent this is crashingly obvious — people who have physical symptoms do not like being told that it relates to emotionality. They see it as “all in your head”.
What somatization – as a defense mechanism — is presenting with physical symptoms caused by clear psychological conflict. This ranges from tension headaches to conversion — what used to be called hysterical paralysis.
Saying cognitive therapy works against usual care is completely unsuprising. The control group matters here. Usual care — and even from the abstract, it’s clear that these were people already in outpatient care — in the USA is not assertive and tends to not pay attention enough to the experience: there is a marked variaition in response to usual treatment between countries. Tom Burns, who Treatment as usual studies should not be done. The comparator arm needs to have the same intensity of follow-up — even if it is reassurance and listening.
So in the end, these studies are worse than offensive. They give a false sense that there is evidence to drive management of unexplained symptoms.
