Medically Unexplained Symptoms: A Brain-Centered Approach

by R. W. Baloh
Springer 2021, 204 pages
Reviewed by T. Nelson

You can't complain that this book asks lots of questions but provides few answers: it warns you right in the title. The theme is that the prevalent ideas about the causes of disease determine what symptoms a patient will present:

Physicians can influence the symptom complex that patients exhibit, and patients are well aware of the symptoms that their doctor expects. This is not to suggest that doctors and their patients are willfully planning illnesses but rather that the symptom complex can be a byproduct of their relationship.

For example, in the 19th century the famous neurologist Jean-Martin Charcot (the discoverer of Charcot-Marie-Toothe disease) and his followers regularly observed hysterical fits, mainly in women, as a common psychogenic illness, but after his death the hysterical fits were no longer observed. Instead neurasthenia, a type of exhaustion and weakness, became popular. This was replaced by Freud's theories about sexual repression, which evolved into his theory of id, superego, and ego, leading to the golden age of neurosis.

Nowadays, the entire concept of psychosomatic illness has fallen out of favor altogether and replaced by neuropsychiatric disorders. Baloh still calls them psychosomatic, including back pain, abdominal pain, ulcers, placebo effect, irritable bowel syndrome, fibromyalgia, chronic dizziness, repetitive stress injury, and even migraine headache. By classifying real and imaginary disorders together as all psychogenic, Baloh is a bit out of touch with most modern thinking on the subject. He brings a subtle wit to the subject but occasionally gets off topic.

There are some clear cases of psychogenic ‘illness,’ such as the case in Belgium in 1999 when a number of school children claimed to have become sick drinking Coca-Cola. The media hyped it up as a poisoning pandemic to sell more papers and poison control centers were sud­den­ly flooded with similar reports. But there was nothing unusual in the Coke: just the normal revolting mixture of brown food coloring, acid, caffeine, and high-fructose corn syrup.

Cases like the one in Blackburn, Lancashire, England in 1966 where 141 schoolgirls suddenly fainted or became dizzy, with 85 taken to the hospital, are eerily reminiscent of Charcot's ‘hysterical fits’ which happened primarily in women. Of course, nowadays saying so is sexist. Likewise, disorders such as ME/CFS (myalgic enceph­alo­mye­litis / chronic fatigue syndrome) predominantly affect women, often at ten times the rate of men. Typically these disorders produce neuro­psych­ological symptoms like hypersomnia, spontaneous pain, and uncontrollable weeping (known as pseudobulbar affect). Unfortunately, calling CFS a psychogenic ailment produces a strong backlash and even harassment from patient groups who are sure it's either neurological or a virus like Epstein-Barr. One CFS researcher joked that he went to Afghanistan and Iraq, where he felt safer.

But migraine patients can verify that their pain is not all ‘in their head,’ or at least not all psychological, but is a real, physical disease. I can personally attest how working with a keyboard at an uncomfortable angle for months can produce numbness and loss of function, which is why I always put a keyboard on my lap. These are no more psychogenic than PTSD, ulcers, or back pain. What they are is proof of the old saying that if the doctor can't figure out the cause of something, it doesn't exist.

nov 21, 2021

Overkill
When Modern Medicine Goes Too Far

by Paul A. Offit
Harper 2020, 278 pages
Reviewed by T. Nelson

In this book, P.A. Offit, MD, a professor of pediatrics, tries to debunk some common beliefs he says are myths. There are many bona fide myths in medicine. There is also lots of contradictory information. That is one reason why you should take this book with a grain of salt (though not too much, even though recent studies dispute that it raises your blood pressure).

Example: Offit says treating fever prolongs or worsens illness, and antipyretics such as aspirin and Tylenol are harmful. Why, then, is the first thing the 17th edition (2008) of Harrison's Principles of Internal Medicine says about fever is this:

[T]here is no significant clinical evidence that antipyretics delay the resolution of viral or bacterial infections, nor is there evidence that fever facilitates recovery from infection or acts as an adjuvant to the immune system.

This is about a strong a statement as you're likely to get, and it directly contradicts Offit's claim. Which one is right? Who knows, but what we do know is that the clinical trial is not to be blamed. Unless a researcher does something technically wrong (such as getting their data from a suspect source or using the wrong test compound), a properly described clinical trial can never actually be wrong. It's simply an observation that something happened, along with an estimate of the statistical noise. The only thing that can be wrong is the generalizations people draw from it.

In the case of hyperthermia, the current thinking seems to be that if the patient is above 106°F—for whatever reason—then something must be done right away.

Offit wonders why it took forty years to implement James Lind's observation that citrus prevents scurvy. One reason might be that he had only two subjects in each group. With such small N, the best he could have hoped for would be a “suggestion” of an effect. Perhaps the British Navy had a better intuitive grasp of statistics than Lind thought.

Much of the book describes how newer clinical trials contradict the results of earlier studies. This raises two questions: (1) Are later studies necessarily more definitive? And (2) what happens when future studies contradict the current ones? It's commonly assumed that newer studies are better and more sophisticated, but this isn't necessarily so: clinical trials haven't changed as much as people think. More often than not, they're done with little regard for the underlying biological mechanism. Sometimes, as with one study claiming that vitamin A caused a 46% increase in the risk of lung cancer, patients were actually given a near-toxic dose of vitamin A (25,000 IU) daily for months. Often they're done in complete ignor­ance of the mech­anism. Usually the biochem­ical mech­anism of the drug under test is simply as­sumed, which is one reason so many clinical trials fail.

In some chapters, as with mammograms and PSA tests, the benefits and risks are fairly described. In others, as in the one on mercury fillings, Offit doesn't consider that the technology for detecting subtle brain dysfunction is not sensitive enough. So while he says mercury fillings are completely harmless, many neurologists would probably say we shouldn't be so sure of our facts, and most dentists now avoid them.

Offit writes “Mainstream dentists don't debate this issue, because it's not debatable.” [p.182] Or maybe, unlike the author, they recognize that we can't be so sure of our facts. My advice: use common sense and be skeptical about anyone who tells you they're 100% sure about anything.

nov 14, 2020

Beyond Weird: Why everything you knew about quantum physics is different

by Philip Ball
Chicago 2018, 377 pages

Reviewed by T. Nelson

Fairly uninteresting book explaining the “weirdness” of QM on a very low level. PC writing style.

nov 02, 2018

Excellent Sheep:
The Miseducation of the American Elite & the Way To a Meaningful Life

by William Deresiewicz
moved to here