4 ms·

> You're assuming that these patients get regularly treated for psych disorders, and that therefore the persistence of this meme indicates it's not psychogenic.

> You're assuming that these patients get regularly treated for psych disorders, and that therefore the persistence of this meme indicates it's not psychogenic. You're overstating my position. I'm saying the question deserves further investigation. You seem to be claiming that it's settled.

arkades 10y ago
> I'm saying the question deserves further investigation. My mistake. > You seem to be claiming that it's settled. No. There are doubtless many rare variants of human ailment we haven't understood or discovered yet. Literally, you could come up with at least one ailment for every enzyme and cell-surface molecule on the human body, at least. My issue is that every few years there comes up a new anxiety/depression fad: some subset of folks with anxiety and depression with attribute it to some new undiagnosed condition (almost always musculoskeletal), and whip up a frenzy. Is it possible that there are these large numbers of usually-musculoskeletal rare disease variants that all happen to look like anxiety and depression? Well, yes, there could be. But considering how woefully under-diagnosed and under-treated mental health is in this country, and that between anxiety disorder and MDD you have a twelve-month prevalence in the US of >20%, you are far, far, far more likely finding people with anxiety/depression and a dollop of either denial or misunderstanding[1]. All of medicine comes down to the Bayesian discipline of figuring out what the most likely cause of an issue is, and collecting evidence to support/disprove that until it's no longer the most likely cause, or until the ordering stops changing. That's it. Jumping down the list is medically irresponsible. Every treatment, at that point, is unethical: you can't justify cost vs. benefit of treatment benefits and side-effects when there's every likelihood the patient doesn't have that rare thing. So, before inventing new diseases every handful of years, we need to stop and say "is there any good evidence that this is a 1/1,000,000 new illness, vs. the anxiety/depression for which there's a >20% chance it is?" In this case, the sum total of evidence for novel disease amounts to the possibility of "possible injury to nasal sensory neurons creates a little numbness in the nose; subject of anxious obsession by pts w/ anxiety." I don't argue this because it amuses me to say "no, silly rabbit, you're not allowed to have your own new disease." It's because these people are suffering terribly, in dire need of help, and when we expend our resources chasing new diagnoses (in the absence of good reason to believe there's a new illness), we're "validating" them at the expense of actually helping them. [1](Yes, patients with anxiety can just genuinely not understand they have it. Anxiety can come on as strictly somatic symptoms, and the common layperson can rationally say "I don't feel anxious or panicked at all; I'm just having trouble breathing. Non-sense!" It's a poorly named disease.)
- haberman 10y ago
  If you had written this comment at the beginning instead of https://news.ycombinator.com/item?id=11651110 https://news.ycombinator.com/item?id=11651110 , I would have had no reason to take exception. This comment makes perfect sense to me. Can you see the difference between the two?
  - arkades 10y ago
    Honestly, no, but I'm glad we reached a point of mutual understanding.
    - haberman 10y ago
      I am too. The first I would paraphrase as: "The patient refuses to accept that his condition is psychological, and we do him a disservice by validating the idea that it might not be." The second I would paraphrase as: "While there is always the possibility that this is a new condition we don't yet understand, statistically speaking it is far more likely to be psychological. Given finite resources, diagnosis and treatment for depression/anxiety is by far the best bet for giving the patient real relief." To me the certainty of exclusion in the first message just immediately sets off alarm bells.
      - arkades 10y ago
        I think part of the miscommunication may lie in professional idiom. In medicine, all diagnosis is provisional and statistical - which both elevates "probably" to "certainly" in casual conversation, and renders most absolute statements hollow. It's just an automatic translation that has to happen: when you tell someone with a three-day sniffle that they have a cold, it's an absolute statement aloud, but in your head you have to honestly say "99.999% cold; 0.0009% HIV; 0.0001% cancer." And you have to treat them accordingly, until proven otherwise, because if you try to rule out cancer on everyone with a sniffle you're going to actually kill more people with complications than you'll ever save. "This person has X" most of the time means "X has a strong statistical advantage in explaining this patient's symptoms, so we're going to pursue treatment for X until accruing evidence suggests we shouldn't." I guess that's not always true, given a few things that exist by definition, but it's mostly true. And that's generally good enough, since... well, statistical masses tend to obey statistical properties.

arkades 10y ago

> I'm saying the question deserves further investigation. My mistake. > You seem to be claiming that it's settled. No. There are doubtless many rare variants of human ailment we haven't understood or discovered yet. Literally, you could come up with at least one ailment for every enzyme and cell-surface molecule on the human body, at least. My issue is that every few years there comes up a new anxiety/depression fad: some subset of folks with anxiety and depression with attribute it to some new undiagnosed condition (almost always musculoskeletal), and whip up a frenzy. Is it possible that there are these large numbers of usually-musculoskeletal rare disease variants that all happen to look like anxiety and depression? Well, yes, there could be. But considering how woefully under-diagnosed and under-treated mental health is in this country, and that between anxiety disorder and MDD you have a twelve-month prevalence in the US of >20%, you are far, far, far more likely finding people with anxiety/depression and a dollop of either denial or misunderstanding[1]. All of medicine comes down to the Bayesian discipline of figuring out what the most likely cause of an issue is, and collecting evidence to support/disprove that until it's no longer the most likely cause, or until the ordering stops changing. That's it. Jumping down the list is medically irresponsible. Every treatment, at that point, is unethical: you can't justify cost vs. benefit of treatment benefits and side-effects when there's every likelihood the patient doesn't have that rare thing. So, before inventing new diseases every handful of years, we need to stop and say "is there any good evidence that this is a 1/1,000,000 new illness, vs. the anxiety/depression for which there's a >20% chance it is?" In this case, the sum total of evidence for novel disease amounts to the possibility of "possible injury to nasal sensory neurons creates a little numbness in the nose; subject of anxious obsession by pts w/ anxiety." I don't argue this because it amuses me to say "no, silly rabbit, you're not allowed to have your own new disease." It's because these people are suffering terribly, in dire need of help, and when we expend our resources chasing new diagnoses (in the absence of good reason to believe there's a new illness), we're "validating" them at the expense of actually helping them. [1](Yes, patients with anxiety can just genuinely not understand they have it. Anxiety can come on as strictly somatic symptoms, and the common layperson can rationally say "I don't feel anxious or panicked at all; I'm just having trouble breathing. Non-sense!" It's a poorly named disease.)

haberman 10y ago
If you had written this comment at the beginning instead of https://news.ycombinator.com/item?id=11651110 https://news.ycombinator.com/item?id=11651110 , I would have had no reason to take exception. This comment makes perfect sense to me. Can you see the difference between the two?
- arkades 10y ago
  Honestly, no, but I'm glad we reached a point of mutual understanding.
  - haberman 10y ago
    I am too. The first I would paraphrase as: "The patient refuses to accept that his condition is psychological, and we do him a disservice by validating the idea that it might not be." The second I would paraphrase as: "While there is always the possibility that this is a new condition we don't yet understand, statistically speaking it is far more likely to be psychological. Given finite resources, diagnosis and treatment for depression/anxiety is by far the best bet for giving the patient real relief." To me the certainty of exclusion in the first message just immediately sets off alarm bells.
    - arkades 10y ago
      I think part of the miscommunication may lie in professional idiom. In medicine, all diagnosis is provisional and statistical - which both elevates "probably" to "certainly" in casual conversation, and renders most absolute statements hollow. It's just an automatic translation that has to happen: when you tell someone with a three-day sniffle that they have a cold, it's an absolute statement aloud, but in your head you have to honestly say "99.999% cold; 0.0009% HIV; 0.0001% cancer." And you have to treat them accordingly, until proven otherwise, because if you try to rule out cancer on everyone with a sniffle you're going to actually kill more people with complications than you'll ever save. "This person has X" most of the time means "X has a strong statistical advantage in explaining this patient's symptoms, so we're going to pursue treatment for X until accruing evidence suggests we shouldn't." I guess that's not always true, given a few things that exist by definition, but it's mostly true. And that's generally good enough, since... well, statistical masses tend to obey statistical properties.