There appears to be a modern obligation to eschew Cartesian Dualism and to and rail against it as the cause of multiple ills. According to Cohen and Quinter, ‘When seen through this Cartesian dualistic frame, pain sufferers appear to a clinician either as a disordered bodily machine or as a disturbed mind.’ In the absence of evidence of a “disordered machine,” the clinician ‘defaults to an inference of a “disturbed mind.”’1 But the dualistic dilemma can be seen in any number of lights. Sometimes the dualism problem is phrased as a Mind-Brain problem; Kirmayer calls it the Mind-Body problem, and illuminates it as a cultural issue:2
Although Western medicine has often been characterized, and criticized, as dualistic and reductionistic, contemporary biomedical physicians are largely unconcerned with the metaphysical “world-knot” of the mind-body problem. Science seems to be slowly untangling this knot, offering a multitude of empirical correspondances between physiology and behaviour that constrain philosophical speculation. Modern biology explains mindful action as an emergent property of the hierarchical organization of the nervous system. A more sophisticated version of this materialism recognizes that mind and consciousness are not simply functions of the isolated nervous system but can be better understood as emergent properties of social systems, that is, of interactions between many individual organisms.
That is, it is being worked out.
However, biology leaves unexplored an aspect of the mind-body problem that is essentially ethical. This residual mind-body problem occurs because mind and body symbolize contrasting poles in human experience: the voluntary or intentional and the involuntary or accidental. It is because the contrast between willful action and impersonal accident is central to both the private sense of self and the public concept of the person that mind-body dualism persists in Western thinking about morally significant events like sickness and disability.
Elsewhere3 he puts somatic symptoms (the essence of fibromyalgia –FW) in a table of ‘Interpretive Frameworks and Potential Meanings of Somatic Symptoms’ where they can represent an:
1. Index of disease or disorder
2. Symbolic expression of intrapsychic conflict.
3. Indication of specific psychopathology
4. Idiomatic expression of distress
5. Metaphor for experience
6. Act of positioning with a local world
7. Form of social commentary or protest
Movement disorders (sometime called conversion symptoms) are a problem for neurologists who are uncertain what to make of patients with such disorders:4
The key clinical feature that separates patients with functional movement disorders from those with organic movement disorders is that the movements have features that one would usually associate with voluntary movement (distractibility, resolution with placebo, and presence of pre-movement potentials), but patients report them as being involuntary and not under their control. There seem to be just two logical explanations for this feature: either movements are deliberately feigned or there must be a brain mechanism that allows voluntary movement to occur but to be experienced subjectively as involuntary. Understanding this mechanism would seem to be key to understanding the development of symptoms and their treatment.
And a survey of British neurologists concerning conversion disorders reported,5
The neurologists endorsed psychological models but did not understand their patients in such terms. Rather, they distinguished conversion from other unexplained conditions clinically by its severity and inconsistency. While many did not see this as clearly distinct from feigning, they did not feel that this was their problem to resolve. They saw themselves as ‘agnostic’ regarding non-neuropathological explanations … One reason for the model’s persistence may be that it is employed as a diagnostic device, used to differentiate between those unexplained symptoms that could, in principle, have a medical explanation and those that could not.
… conditions that do not readily fit the clinician’s model of care and practice can place patients in moral jeopardy. Carl May and colleagues found that physicians quickly make evaluative judgments of patients’ motives, the legitimacy of their symptoms, and the congruence between the physician’s and the patient’s conceptual model of illness.
Banks7 noted of patients with chronic fatigue (fibromyalgia’s first cousin) that
In the realms of symptoms, aetiology and treatment evaluation, lay people in the CFS clinic have quite distinct ideas about what their problems are and how they might be analysed and managed—ideas that are often in conflict with those of medical professionals. Thus, lay sufferers, for example, operate within a different conceptual terrain from that of many professional experts. They are more likely to refer to a disease (myalgic encephalomyelitis or ME), rather than a syndrome. They call upon different kinds of hypotheses to explain their symptoms. They hold to conflicting ideas about the order of causal sequences, and they give emphasis to different kinds of phenomena in their accounts of illness. As a consequence, clinical consultations can often take on the form of a political contest between physician and patient to define the true and real nature of the patient’s disorder—a micro political struggle in which neurological symptoms can be re-framed as psychiatric symptoms, and psychiatric symptoms as neurological. In short, a contest in which the demarcation lines between mind and body are continually assessed and re-defined, and the tenets of ‘biomedicine’ are constantly challenged
In an email, Nancy Ryan calls attention to an article by Siri Hustvedt entitled, ‘Philosophy matters in brain matters.’8 Hustvedt is a highly regarded writer who happens to suffer from migraine and ‘medically unexplained seizures,’ and wrote about it in a book called ‘The Shaking Woman or A History of My Nerves’ that was published in 2009. Another name for her problem is psychogenic non-epileptic seizures (PNES), which the Wikipedia describes as ‘events superficially resembling an epileptic seizure, but without the characteristic electrical discharges associated with epilepsy. Thus, PNES are regarded psychological in origin, and may be thought of as similar to conversion disorder.’
It’s not possible to summarize Hustvedt’s important article—read the whole article, but the abstract gives the flavor:
Purpose: Although most neuroscientists and physicians would argue against Cartesian dualism, Descartes’s version of the psyche/soma divide, which has been controversial since he proposed it in the seventeenth century, continues to haunt contemporary neurological diagnoses through terms such as functional, organic, and psychogenic. Drawing on my own experiences as a person with medically unexplained seizures, I ask what this language actually means if all human experience has an organic basis.
Methods: Close reading of a textbook chapter on psychogenic seizures.
Results: I expose the author’s unreflective embrace of psyche and soma as distinct entities, his inherent bias against illnesses labeled psychogenic, and the implicit sexism of his position. I further argue that even when a patient’s symptoms are not alleviated, heightened self-consciousness and narrative framing can strengthen his or her sense of agency and have therapeutic benefits.
Conclusion: The ethical treatment of patients requires a respect for their stories.
She concludes, ‘Although some empathy in one’s doctor is certainly desirable, an ethical position requires respect, above all, the simple recognition that the patient in front of you has an inner life as full and complex as your own.’
If it is not entirely clear what these illnesses mean or what dualism means, we can value as being complete and correct Hustvedt’s call: ‘The simple recognition that the patient in front of you has an inner life as full and complex as your own.’
For now, one path, quoted by Scheurich9 and in line with Kirmayer’s ideas, is that that we should understand clinical problem simultaneously as diseases, dimensions, behaviors, and life stories. Things are true or false or unclear depending on who we are and where we are. But the patient in front of us has an inner life as full and complex as our own.
1. Cohen, M., Quintner, J., Buchanan, D., Nielsen, M. & Guy, L. Stigmatization of patients with chronic pain: the extinction of empathy. Pain Medicine (2011).
2. Kirmayer, L.J. in Biomedicine examined 57-93 (Springer, 1988).
3. Kirmayer, L.J. & Young, A. Culture and somatization: clinical, epidemiological, and ethnographic perspectives. Psychosomatic Medicine 60, 420-430 (1998).
4. Edwards, M.J. & Bhatia, K.P. Functional (psychogenic) movement disorders: merging mind and brain. The Lancet Neurology 11, 250-260 (2012).
5. Kanaan, R., Armstrong, D., Barnes, P. & Wessely, S. In the psychiatrist’s chair: how neurologists understand conversion disorder. Brain 132, 2889-2896 (2009).
6. Hill, T.E. How clinicians make (or avoid) moral judgments of patients: implications of the evidence for relationships and research. Phil Ethics Hum Medicine 5 (2010).
7. Banks, J. & Prior, L. Doing things with illness. The micro politics of the CFS clinic. Social science & medicine (1982) 52, 11 (2001).
8. Hustvedt, S. Philosophy matters in brain matters. Seizure (2013).
9. Scheurich, N. Moral attitudes & mental disorders. Hastings Center Report 32, 14-21 (2002).