Their pain is real – and for patients with mystery illnesses, help is coming from an unexpected source

Hoopoe

Hoopoe

Senior Member (Voting Rights)
At his psychiatric clinic at QEII Health Sciences Centre in Halifax, Allan Abbass is showing video clips of his therapy sessions.

A man arrives via wheelchair, dragging frozen feet the last few steps, leaning heavily on a cane. He takes a seat, talks to Dr. Abbass. When he leaves, he carries his cane under his arm.

A pixie-haired woman who has not spoken for a month sits before him in another clip. She’s been seen by a team of doctors, who found nothing. By the end of the first session, she speaks, in full, clear sentences.

A middle-aged office manager with an uncontrollable tremor is being considered for brain surgery; 90 minutes of therapy later, she triumphantly waves a stapler in the air, her tremor gone.

Dr. Abbass knows how it sounds. He’s used to skeptics, at least until he rolls the tape.

But these aren’t miracles, he says. This is science.
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I'm still skeptical. It sounds like he is encouraging patients to hide their symptoms and behave more normally, and even a temporary change in that direction is taken as evidence that a mysterious mind-body illness was successfully treated.

This is also not innovative. It's the same old Freudian claim of being able to cure physical symptoms with talk therapy.

https://www.theglobeandmail.com/lif...-for-patients-with-mystery-illnesses-help-is/
 
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I found it quite an interesting article. I think there are some people whose physical symptoms such as nausea, pain etc. may be at least partly a result of psychological stress or childhood abuse, and good quality therapy that enables them to understand this better and get some release of anger, grief etc can help. But my concern is the extension of this or any other therapy as a 'cure all' for everyone with 'MUS'.
 
Wonko said:
It's been done before, it is always a sham, a few weeks later, or even once the camera stops running, there is no improvement.
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You may well be right, @Wonko. I'm not suggesting the therapy has any relevance to ME, but it may be helpful for some symptoms for some people. For example, I know my gut behaves differently when I am very stressed. Extrapolating from that I think it's possible that if someone is suffering severe continuous stress, it could cause severe and continuous gut problems.

Or perhaps I've just been sucked in by a plausible sounding article. And wishful thinking. I wish I could do a few sessions of therapy and my ME magically disappear. Sigh! The only therapy I've tried just pissed me off for being worse than useless.
 
Trish said:
I know my gut behaves differently when I am very stressed. Extrapolating from that I think it's possible that if someone is suffering severe continuous stress, it could cause severe and continuous gut problems.
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just to highlight the dangers here - a relative had gut problems most of their life and much of it was put down to stress. As was a stomach ulcer. So when their symptoms became quite bad they didn't complain or do anything about it. Then they dropped dead. It turns out they had been having a series of mini heart attacks that just felt like their usual stomach symptoms. Finally, one massive heart attack killed them.

I had very similar gut symptoms that I can completely control through diet. Relaxation and meditation make naff all difference to symptoms. Eating carefully can. Nothing to do with stress at all.

This approach has as much potential to cause or prolong suffering and even death as using an inappropriate drug. However, in the case where misuse/misprescription of a drug might trigger an investigation, this quackery won't. No lessons learned.

A pixie-haired woman who has not spoken for a month
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WTF is pixie hair? And what has that to do with anything?

90 minutes of therapy later, she triumphantly waves a stapler in the air
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1. If you're waving your hand in the air, people will be far less likely to see or notice the tremor.
2. Why would a person facing brain surgery for uncontrollable tremors add to their burden by taking a stapler everywhere they go? Unless they were provided with one by the therapist for the purposes of demonstrating successful treatment. But that would mean the filming was staged.....

Maybe I got out of the cynical side of my bed this morning?
 
Abbass' 2009 systematic review and metaanalysis reveals basically no improvements on objective findings in the few studies that bothered to measure them. The one outcome that was occasionally measured was healthcare utilisation, but it is important to note that less healthcare utilisation can also be a negative result due to problems that patients encounter during healthcare practitioner interactions. There was no difference in hospitalisations for Coronary heart disease patients for example.

Even on subjective reports (self report or rated by someone else), most of the studies had neutral or very small effects for somatic symptoms and there were no differences for somatic symptoms at long term (9+ months) followup.

His study concludes (read: the evidence is only of 'suggestive' quality)

The somewhat positive results of this review should be interpreted within the following limitations. First, the included studies were of variable methodological quality, conducted with a broad range of scientific rigor. Second, there is a high probability of selection bias in some of the studies, although in the 13 RCTs the use of randomization should have mitigated between-group differences as a confounder. Third, there is possible reporting bias, where striking positive (stopping smoking) or negative events (vagotomy surgery) would be more likely reported in only some studies. Fourth, most of the treatments were neither manualized nor adherence rated to ensure treatment standardization. Fifth, only 4 and 5 of the studies in the meta-analysis had medium- and long-term followups, respectively. Finally, the heterogeneity in most metaanalyses, the loss of significance in some cases using random-effect modeling and the inclusion of only 14 studies suggest that the meta-analysis results need to be interpreted with caution.
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Invisible Woman said:
just to highlight the dangers here - a relative had gut problems most of their life and much of it was put down to stress. As was a stomach ulcer. So when their symptoms became quite bad they didn't complain or do anything about it. Then they dropped dead. It turns out they had been having a series of mini heart attacks that just felt like their usual stomach symptoms. Finally, one massive heart attack killed them.
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Yup. My partner's aunt had stomach aches and pains for months and it was all put down to stress. Finally the pain became so bad that she was taken to the ER. They quickly discovered she had stage 4 cancer. Two months later she's in a hospice waiting to die.
 
Is there any objective evidence that 'conversion' of hypothesised trauma into somatic symptoms ever actually occurs?

These supposed conversion symptoms are presumably very different to PDST as they do not even require that you remember the presumed trigger event. Do people ever define their theories clearly enough to experimentally evaluate them?

Obviously it would not be possible to do a blinded randomised control on this intervention, but what, if any, evidence would Dr Abbass accept as disproving his theory, or would he always have a let out for when it does not work: eg they turn out to have a biomedical condition, they have not sufficiently processed the emotion involved so need more therapy (both possibilities are mentioned/ hinted at in the article).

Does this theory have any predictive value? Can Dr Abbass predict what childhood traumas will cause what somatic symptoms, can he predict who will respond how quickly to his intervention?

Can he distinguish his cures from spontaneous recovery, or be certain that he has produced lasting change or short term 'brain washing'? How many of these patients are followed up long term?

Does he have any objective measures of the presenting somatic symptoms that enables him to quantify change other than his and his patients beliefs? Given the suggested emotional intensity of the intervention can he be sure he is not impacting on reporting behaviour rather than actual symptoms?

One area where 'magic' instantaneous 'cures' do occur relatively frequently is with stammering. It is thought that an underlying congenital neurological issue predisposes people to stammer and that this can not be cured but people can learn to manage it. Stammering is interesting in this context because during WWI private soldiers were believed to more often develop bodily hysteric symptoms due to shell shock whereas officers were more likely to develop speech symptoms.

With sufficient conviction any self proclaimed therapist can come up with a quack stammering treatment that will produce appearant cures. However this invariably does not last more than hours or days or occasionally weeks. To produce reliable long term changes in a stammerer's speech they need to put work into teaching a conscious understanding of fluency techniques, then to practice enough for it to become a skilled behaviour and then do further work on generalising that fluency behaviour to everyday life. Psychotherapy may help individuals overcome the issues that have arisen from their negative experiences of other people's bad reactions, but does not directly treat the underlying stammer.
 
I would have thought that if one looks at such things from a systems perspective, there will inevitably be very rare cases where the part of the system that develops a fault may be the mental processing part - which is a crucial part of the overall system. I think that statistically it is going to happen in some cases (why would it be magically exempt?), and would be amazed if such failure modes were impossible, even though extremely unusual.
 
I agree @Barry it is quite possible that for some this "mental processing" part may be at fault. However, just because it's possible that this may be true for some shouldn't then just be extrapolated to apply to all. This is where the problems start.

Where is the science behind such extrapolation? Because they are using a theory which can neither be proved nor disproved as the starting point no meaningful data can be gleaned (I think).

If we instead take the opposite approach that assumes a non psychogenic cause, then assess efficacy of treatments we're more likely to get more useful information, though I guess at the end we would still be left with a group where the cause is either still unknown or psychogenic.

I have seen the argument that testing and treating can cause iatrogenic harm and I can see how that would be. However, what about the harm caused to people who are left suffering and struggling on for decades, dismissed as being "stressed". Let alone the ones who may actually die.

Where is the research to show which approach is most effective, by which I don't just mean cost effective, but gives best improved quality of life & health for money. NICE's remit.

Where's the science?
 
It can, at least, be said that this therapist is no more bizarre than a certain Michael Sharpe:

(Of treatment with CBT) It is useful at this point to consider how much treatment a patient needs. Some patients find the initial formulation not only acceptable but a revelation. They may immediately start making suggestions about how they could change their attitudes, behaviour and life style in a way that will unlock them from the vicious circles they now perceive. These patients may only need encouragement and follow-up to check that they remain on course. I have known patients who have recovered after a single telephone conversation that enabled them to reconceptualise their illness, reduce their fear of symptoms, and overcome their avoidance.

Michael Sharpe. Chronic Fatigue. In Science and Practice of Cognitive Behaviour Therapy (1997) eds David M Clark and Christopher G Fairburn @p400

He does go on to describe greater difficulty for other patients. He does also at the outset point out the distinction between chronic fatigue, the symptom, and chronic fatigue the syndrome, but then fails to clarify to what he refers.

It is odd that this anecdote is related to indicate the success of the treatment, rather than the failure of the categorisation, or the diagnosis.
 
Quick background - dry eye and eye pain was often dismissed because nothing was apparent on examination, but doctors who believed patients worked with them and a lot of work has now been done (if only it was like that for us!) They have developed promising treatments but there seems to be a snag. They work beautifully for a while but eventually things go back to the way they were.

In the eye system, the brain senses the atmosphere and fine tunes it constantly. What seems to be happening in some cases is the the brain has got the settings wrong. It seems analogous to the way the immune system makes a mistake and misreads essential parts of the body. Something like that is spoken about with FND but it is not anything to do with psychology or thoughts!

My hands keep going into fists, sometimes worse, sometimes less. When I notice it I can loosen them but as soon as my attention moves on back they go. During the night I have little bean bags that stop my nails cutting into my palms.

The brain is complex, so much can go wrong that it is infuriating to dismiss it all as behavioural when a proper study could bring so much knowledge and has the potential to relieve so much suffering.
 
Invisible Woman said:
I agree @Barry it is quite possible that for some this "mental processing" part may be at fault. However, just because it's possible that this may be true for some shouldn't then just be extrapolated to apply to all. This is where the problems start.
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Clearly you are right, and is of course what I was saying. Such extrapolation is akin to convincing yourself a field is perfectly flat, and then presuming the earth is therefore flat also ... now where have I heard that before?
 
Barry said:
I would have thought that if one looks at such things from a systems perspective, there will inevitably be very rare cases where the part of the system that develops a fault may be the mental processing part - which is a crucial part of the overall system. I think that statistically it is going to happen in some cases (why would it be magically exempt?), and would be amazed if such failure modes were impossible, even though extremely unusual.
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First of all, there are selection biases against that - most brain diseases mean the offspring is not viable. Secondly, such failure modes would present in a specific way - namely have distinct signs that the failure is mental.
 
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