Functional neurological disorder: lighting the way to a new paradigm for medicine, 2021, Edwards

Latest empire building spam from Edwards.

Abstract

What if the patients most health professionals actively seek to avoid, people with “medically unexplained” or functional symptoms, were those who hold the key to a more successful, more rewarding and more just system of medical practice for all? I think they do. They force us to answer the question, to paraphrase Wittgenstein: What is left over, if I subtract the fact that I have a disease, from the fact that I am ill? Within the answer to this question is the human, participatory aspect of illness, which, despite hundreds of mission statements to the contrary from healthcare organisations the world over, is not adequately addressed in our medical training, practice and principles. We can and should do better, and this is a proposal for how.

Paywall, https://academic.oup.com/brain/advance-article-abstract/doi/10.1093/brain/awab358/6380940

 

I don't know how he manages to work Wittgenstein into that. Philosophical Investigations para 621 LW said this:

621 Let us not forget this: when "I raise my arm" my arm goes up. And the problem arises: what is left over if I subtract the fact that my arm goes up from the fact that I raise my arm?
(Are the kinaesthetic sensations my willing?)

622 When I raise my arm I do not usually try to raise it.

(the bold replaces italics in the original). This does not seem entirely analogous.

 

This is such a nonsense that it is already good again, though in a another manner.

So what if they are doing their job by not doing it? I thing they do it.

Thanks to @chrisb I ask myself now, what is left over from my illness if I not try to be ill? The illness? The try, that does need a doctor? An ill try, that doesn´t need a doctor?

End of the abstract - the answer has already given. What a great work!

---
But I would say, that in the quote thankfully given by @chrisb, Wittgenstein is wrong. Because doing is trying, which is apparent, when the doing doesn´t succeed, which us inherent to any doing. Imagine e.g. that a scientist would not be able to fail, or that my grandfather still could get out of his chair when he tried so hard.

I admit, I ever thought, late Wittgenstein is nuts. I remember though also, that it used/s commonly to get misinterpretated by philosophers, same with false perception, which wouldn´t be "real" perception, so rather any perception (also without any object in correspondence to its access.)

edit: changed "knowledge" to "perception" (the basic knowledge, as might be said)

 

But is "doing" "trying"? There is a passage in section 11 of chapter II of The Brown Book discussing volition, deliberate and involuntary actions. He clearly had a party game. Though he probably would not have been a bundle of fun at a party. You can try this at home.

If, eg, I place myself sideways close to a wall, my wall-side arm hanging down outstretched, the back of the hand touching the wall, and if now keeping the arm rigid I press the back of the hand hard against the wall, doing it all by means of the deltoid muscle, if then I quickly step away from the wall, letting my arm hang down loosely, my arm, without any action of mine, of its own accord begins to rise; this is the sort of case in which it would be proper to say, "I find my arm rising".

 

Cartesian dualism, innit.

 

The quote is well very instructive. In the case that I find my arm rising, the arm is indeed something I have, and it is in so far something in the outer world. It is also no caveat to further refer to nerve action, which here involuntarily should be responsible for the rising arm.

But when I want to rise my arm, and may succeed with this wanting, my arm indeed does rise, and this is a doing.

I might though not succeed, and may say, I at least tried it. In this case one may say, I didn´t do it, right, but both was equally a try, in the case of success as well as in the case of failure. So, how can Wittgenstein say, that I wouldn´t try to rise my arm? Everything what I do is a try, and in basic doings I mostly succeed.


I am afraid that Edwards might even have corrected Wittgenstein here, with his distinction between "disease" and "illness", only that a) the distinction referes to an inner difference in the complex act of the unity Doing (here behaving ill), and b) that his proposal is not necessarily true and is empirical unproven (and may well ever stay so).

 

But is it, at least as far as LW was concerned, or is that a category error? Surely LW was merely indicating the ways in which language is used, and the beliefs and expectations which that usage engenders. Wasn't Gilbert Ryle in some senses a successor to LW, and his ideas are the opposite of Cartesian dualism?

 

This "new" paradigm literally predates 95%+ of all the content in medical textbooks, but OK, I guess you can call something well over a century old "new" if you want to, what I don't understand is how a self-respecting journal would not object to calling something that literally predates the commercialization of electric power as new, in a field that is expected to renew itself almost entirely every 1-2 decades.

This is Deepak Chopra level of weak sauce, zero difference between this and religious zealots. And "patients we seek to avoid" is incredibly unprofessional, there is nothing positive about literally refusing to do your job when you are a statutory monopoly, it only shows how empty the words about "duty" and "oaths" are.

 

Not LW, although he got so cynical about philosophy that it is hard to know if he believed anything at the end.

Cartesian Dualism is of course itself a category error, because, as understood by the people who own the term, it bears little relation to the thinking of Rene Descartes.

I would post a copy of my chapter on Descartes in Paul Hackett's monograph on categories but I think it would be getting too far off topic.

Chomsky is worth reading on Ryle because he points out that Ryle is in many ways a caricature of the error he attributes to Descartes. His is a much worse dualism but not so different from Cartesian Dualism since it makes the same category mistake about what Rene thought.

Ryle is very confused. He himself points out half way through the Concept of Mind that rather than complaining about Descartes putting a ghost in the machine he is actually annoyed by him put a machine in the ghost. Ryle wanted Oxford philosophy to own the mind rather than science. His attempts to retain stewardship are incoherent gibberish to my thinking.

My comment was directed at the author of the paper. Illness without disease implies non physical causes. For Descartes the mind's action on the body was physics, just as God's action on billiard balls was. The great mistake of the dualists who followed Descartes is that they assumed he meant mind to be non-physical (rather than just non-material). Descartes is to a large extent guilty of giving rise to this error through his letters to Princess Elizabeth of Bohemia.

Perhaps the moral of the story is that these doctors not only have no clue about Descartes. They also have no clue about Wittgenstein.

 

I wonder whether they have a clue about the illness/disease dichotomy and its use by the likes of Eisenberg, Kleinman and Cott in the illness behaviour model. Perhaps it is is best not to mention that. It seems to have been deliberately avoided all these years.

 

I am not up to thinking about philosophy these days but as someone who is talking about FND (and many of my ME symptoms could be squeezed into that category) he appears to have no clue about the disease he is talking about.

I go to raise my arm in the same way as I always do but sometimes nothing happens. ME subtracts the movement of my arm from the fact I raise my arm.

They make out they are talking about an illness without disease but can only do so by ignoring all symptoms of disease.

 

Some quotes from the article:

 

There is something weird about how the word "rehabilitation" is being used. As if it is not a medical intervention like others and that needs to be tested to see if it works or not.

Rehabilitation seem to work by definition. The only limitation is that it cannot be done to patients. It requires their participation. So if it doesn't work out well, you know how is to blame.

 

In the final sentence of the abstract he says they must do better. Well... You'd do a great better by stopping the reinforcement of stigma & 'othering' that you are perpetuating in your opening statement, which sets the tone for the entire paper.

precisely.

 

Indeed.

how do we deal with the problem that, as currently constituted, these methods are not easily applicable to understanding the complex interface between biology and environment that occurs within humans who are ill, and therefore to studying the process of rehabilitation?

You get on and apply them with care, just as clinical pharmacologists do. Applying them to drug treatment is tricky too. It requires a huge amount of work and a lot of money. Somehow rehabilitationists seem to think they can bypass that.

Something that struck me recently is that if these treatments actually worked then there really would not be too much trouble using standard methods. If the treatments really worked there would be a robust dose effect that could be studied using dose response relations that are much less subject to bias problems.

With drugs that work loosely designed studies show enormous apparent effects. More careful studies cut those effects back a bit. The one thing about PACE that nobody can disagree with is that the results were hugely disappointing - so much so that the authors changed the outcome criteria - even they knew it was disappointing. If you do a loose trial and get seriously disappointing results the problem is not the difficulty of doing trials. It is that the treatment doesn't work.

To move forward, we first need to recognise that the crown of legitimacy claimed by evidence-based medicine is tarnished, precisely because it fails to deal with the influence of the personal in medicine

Er, no. The crown of legitimacy is not tarnished because it is precisely because it deals with the influence of the personal (bias) that it gives reliable results. Any alternative that ignores the influence of the personal on trials is doomed to failure.

And as Michiel says, what has this word 'rehabilitation' got to do with it. For illnesses like RA we jettisoned rehabilitation for treatments that worked about twenty years ago.

This really is the pits, intellectually.

 

It fails to account for almost all things because it's an oversimplistic approach that does exactly that. It's not unique or even particular to medicine: models are not reality. But here is a textbook example of people holding a model above reality.

EBM is not supposed to be used alone, it cannot fulfil its purpose without either a theoretical basis before or after, in itself it's a useless paradigm. It's amazing how every time they tell the truth, it's always backwards, so not the truth. It's true that EBM has failed, but the fault is 100% on the supply side, all thanks to the benevolent dictatorship model of medicine where the patient has no place other than to comply on command and otherwise be silent.

But even this argument is old, it's literally the trope behind CBT-GET "works", it's the patients who are failing. They've been arguing this for years, the spoon would have bent if we weren't skeptical of the fact that it wouldn't (and also because we don't allow you to bring your own special alloyed-spoons that you use in your artificial setting).

At this point I'd frankly question the validity of most "rehabilitation" out there, given the complete lack of seriousness at dealing with the failures of this approach. It looks mostly as a stand-in for taking credit for the passage of time.

 

I didn't read beyond the first two words.

 

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