Critiques of psychosocial illness explanations

Critical Analysis of Psychological Illness Explanations​

The only certainty Is uncertainty: Doctors should admit when they don't have an answer
Frances, A
2013
link to article
This article argues that medical professionals are overconfident about their diagnostic abilities, and fail to appreciate the limits to our current medical understanding. Consequently, symptoms that ‘defy quick and accurate diagnosis’ are labelled in ways that imply they have a psychological origin. He writes, ‘Cases of medical uncertainty become cases of psychiatric certainty, not through investigation or evidence, but by default, simply as a function of the way the words are used.’ Frances urges medical professionals to embrace the concept of uncertainty, and to accept that not all unexplained symptoms necessarily have a psychological or a psychiatric basis.

Medically unexplained symptoms and the disease label
Jutel, A.
Social Theory & Health
2010
link to article
This paper examines how the term medically unexplained symptoms (MUSs) has been used in recent medical articles. The majority of such articles treat MUSs as a unitary diagnostic category and assume a common psychological/psychiatric cause. Only a quarter of the articles reviewed directly criticised this assumption. The author argues that psychological accounts of MUSs exploit the uncertainty associated with psychological/psychiatric diagnosis. This approach is harmful, she argues, because it shifts responsibility for explaining the symptom from the doctor to the patient: “there is a hasty progression from lack of explanation to considering a patient's behaviour ‘abnormal’”. The conclusions are a bit wishy-washy, but there are some good references to other relevant critiques.

Authors of our own misfortune: The problems with psychogenic explanations for physical illnesses.
Kennedy, A.
2012 book. South Willingham, England: Village Digital Press
link to Aeon article that summarises some of the book's key arguments
This book critiques psychosocial explanations of illness from a sociological perspective. It argues that such explanations rest on certain moralistic and ideological assumptions about people and their illnesses. Proponents of these explanations fail to scrutinise these assumptions. Many of the examples are from MECFS, and the book references a number of research articles and other sources related to psychosocial explanations, their problems and their dangers.

Psychogenic explanations of physical illness: time to examine the evidence.
Wilshire CE, Ward T.
Perspectives on Psychological Science. 2016 Sep;11(5):606-31.
link to article
This article focuses primarily on patients presenting with unexplained 'neurological' symptoms (e.g., seizures, movement disorders), which are commonly attributed to 'psychological' factors. It scrutinises the supporting evidence for these explanations. The article concludes there is insufficient positive evidence to support any of the current psychological/psychosocial accounts for these disorders, and that the absence of medical evidence, on its own, is insufficient evidence of psychological dysfunction. Many of the arguments made in the paper apply more generally to all kinds of medically unexplained illnesses.

The biopsychosocial approach: a note of caution
Chapter 5 In An integrated approach to understanding illness Edited by Peter White
George Davey Smith
Paperback
2005
link to article (link updated Feb. 2021)

Should Your Response to Pain Be Considered “Abnormal”? Somatic symptom disorder and DSM-5
Barrett, D.
Psychology Today
2013
link to article (link updated Feb. 2021)

Charcot's Bad Idea
Overton, S.
Paperback February 15, 2009

Why Freud was wrong
Webster, R.
1995 (book)
link to web article with key excerpts

Reports documenting the consequences of a 'psychological' misdiagnosis​

The voice of 12,000 patients: Experiences and expectations of rare disease patients on diagnosis and care in Europe.
Kole, A., & Faurisson, F.
Report published in 2009.
link to report
This report does not critique psychosocial explanations directly. However, it presents statistics from a large cohort of patients with various rare diseases. Patients who were initially misdiagnosed as having a psychological problem (or an illness commonly believed to have a psychological cause), experienced a greater delay in diagnosis, when compared to those who were initially medically misdiagnosed. The average delay varied across the different diseases, but in some cases was as high as six years (p. 48). These statistics illustrate the subtle but powerful way in which a psychological diagnosis influences subsequent medical decisions.

Psychological versus biological clinical interpretation: A patient with prion disease.
Solvason, H. B., Harris, B., Zeifert, P., Flores, B. H., & Hayward, C.
American Journal of Psychiatry. 2002 159: 528–537.
link to article
This extraordinary article reports on a patient who presented with neurological symptoms of no known origin. She was diagnosed as having conversion disorder (a psychiatric diagnosis). Initial reports of the case described the various 'secondary gains' she obtained by occupying the illness role (the chance to repair her relationship with her partner and family, the opportunity to avoid work). She died shortly thereafter, and was found on autopsy to have prion disease, a degenerative neurological disorder.

Problems with diagnosing Conversion Disorder in response to variable and unusual symptoms
Barnum, R
Adolesc Health Med Ther
2014
link to article
This article examines the potential dangers of misdiagnosing children with Conversion Disorder (CD), which assumes that the symptoms are an unconscious manifestation of some underlying psychological problem. It describes the case of a young girl, initially misdiagnosed with CD, and later diagnosed with Ehler Danlos syndrome. The author discusses how the CD diagnosis can impede progress towards the correct diagnosis, and can persist in the child’s medical records for years, undermining their access to future medical care. He claims that children react to the diagnosis very negatively, and quickly see through attempts to soften it (e.g. “your brain is playing tricks”). The child feels disbelieved, and once trust is lost, even those who might have benefitted from mental health care will likely reject that approach.

Why Bioethics Should Be Concerned With Medically Unexplained Symptoms
O'Leary, D.
The American Journal of Bioethics, 18:5, 6-15
2018
link to article (link updated Feb 2021)

First person accounts of the harms of psychologising illness​

Turning patients into numbers.
Mildon, B.
blog post, 2015
link to blog
This blog is written by a patient who was initially misdiagnosed with conversion disorder (it subsequently turned out she had Sneddon's syndrome). The author talks about the psychological harm done by this misdiagnosis. She was taught to question the validity of her own testimony, and even her own sanity. The article also talks about the way such a psychological misdiagnosis negatively affects all subsequent medical consultations, and ultimately, leads doctors to dismiss a patient's legitimate complaints.

Understanding the narratives of people who live with medically unexplained illness.
Nettleton, S., Watt, I., O'Malley, L., & Duffey, P.
Patient Education and Counseling. 2005 56: 205–210.
link to article (link updated Feb 2021)
This interview-based study aims to identify the themes in patients’ descriptions of their illness journey. It examines patients’ perspectives, without commenting on the validity of the (psychological) illness explanations they had been given. Nevertheless, it’s a good resource for patient quotes about the experience of receiving a psychological diagnosis. One patient describes how she was made to feel it was ‘her fault’ and that she felt like ‘a failure’ for being unable get her symptoms under control.

Gender-biased Diagnosing, the Consequences of Psychosomatic Misdiagnosis and 'Doing Credibility'
Clare Smith, E
Thesis, 2011
link to thesis (link updated Feb 2021)