This trhead is still going?

longwood8 said:WalStMonky said:Well I have to change my mind. Now that epiphemomena has been mentioned I'm all ears. I love learning new words.

Damn this thread. Since reading it this morning I can't get that damn "Girl from epiphenomena" song out of my head.

The song was "The Girl from Ipanema", circa 1965.

fromtheFUTURE said:Eric talks about secondary gain and no one has used that since the 70s.

"This reasoning of tying the most chronic problems to psychological causes also defies basic knowledge of brain chemistry. Researchers are now more informed than ever about the process of “chronification” of disease in the brain. According to advanced brain scans – which now render very few illnesses truly “invisible” – the brain, when pummeled with repeated pain attacks, becomes vulnerable to “central sensitization.” That means that the central nervous system becomes overly sensitive and stuck in a pain feedback loop."

That's from an article today in the Times. She also takes to task people like Eric.

"According to creaky psychoanalytic thinking, the more chronic something is, the more the patient is getting something from it, termed as a “secondary gain.” This philosophy was officially thrown out of medicine in the 1970s, but still persists, not so much in medical texts, but in self-help books for general audiences. This is even the case in one of the top-selling mass-market headache-prevention guides of the decade, Dr. David Buchholz’s “Heal Your Headache.” While he certainly gives much valuable advice about lifestyle tools for prevention, he blames those most severe patients who don’t get better with his plan.

http://migraine.blogs.nytimes.com/author/pkamen/

sadly, this author's credibility is a bit in doubt since she has confused "secondary gain" with the totally unrelated "primary gain."

primary gain, which is actually what she describes, is the unconscious/preconscious act of gaining comfort from being a sick patient, in this case a "failed CDH sufferer."

secondary gain is the conscious act of gaining a material advantage through symptoms, such as disability income, sick days off work, prescribed narcotics, or assistance with household chores. Faking symptoms for secondary gain is called malingering.

At any rate, both primary gain and secondary gain are alive and well in medical practice, political correctness notwithstanding. That is not to say that all or most (insert poorly understood medical syndrome here) sufferers are fakers; only that some percentage of those patients claiming disability, asking for narcotics, or requesting time off work will be a. faking it, or b. manifesting a psychological need in a physical manner.

For completeness seek, it is helpful to think of behaviors on a two axis grid. The x axis is "awareness" and the y axis is "intention." These behaviors are not black and white; they exist on a continuum.

highly aware + highly intended are voluntary, self-aware activities, such as faking a headache to obtain a prescription for Vicodin. This is called malingering.

highly unaware + highly unintended is the classic conversion disorder (ie, a patient experiences total paralysis of his arm whenever he witness a violent movie).

highly aware + highly unintended are certain somatization disorders - patients who experience a broad range of physical symptoms but understand that these symptoms reflect underlying psychological distress. A classic somatization is abdominal pain before a big test.

highly unaware + highly intended is Munchausen's syndrome (intentionally creating physical symptoms in order to be in the sick role. An example is the disabled nurse who visits dozens of hospitals with mysterious blood infections, only to be observed injecting herself with her own feces.)

All in all it's a very interesting area of psychiatry.

One other very important mistake from the article (and some of the posts above) which I wanted to clarify: "seeing" something on an fMRI, a PET scan, or a SPECT scan, doesn't necessarily prove there is a "real" biological phenomenon. It is well-known that patients who respond to placebo in antidepressant trials have the exact same brain changes on fMRI as patients who respond to antidepressants. It is unlikely that the placebo itself caused the changes in glucose metabolism; it appears to be the expectation of being better which is important. Don't put too much stock into a few published functional imaging studies, which typically have very small sample groups and where positive publication bias may be very misleading.

fromtheFUTURE said:She says "the more chronic something is, the more the patient is getting something from it, termed as a “secondary gain."

only if the 'something' is material in nature; if it is psychological, ie 'identifying as a sick patient', which is the context in which the author used the term, it is primary gain. She is simply wrong.

fromtheFUTURE said:And if there is a real response to a placebo on an fMRI, then that is a biological result. And, no, the scans are never the "exact same brain changes."

in a sense, everything is biological. it depends how reductionist you want to be. my point was that unless you believe that placebo pills are effective antidepressants, seeing something on a functional imaging scan does not prove the reason that finding exists; nor does it prove cause vs effect; nor does it prove nature vs nurture. It proves that at that moment in time, there is a finding in the brain's metabolism; nothing more.

fromtheFUTURE said:There are unfortunately some posts in this thread from doctors who have a low regard for patients ability to report their own symptoms and very high regard for their own opinions. They are quick to point out the errors of others, but slow to acknowledge their own. They have a poor ability to empathize and trust other viewpoints. In the mental health field, they are called "broken healers."

Healthy skepticism is healthy for patients; it's an intrinsic part of challenging their world view which fundamentally hasn't worked for them, hence their appearance in my office. Apparently you believe that there is no reason for patients to (intentionally or not) misrepresent symptoms. You live in a fantasy world. I live in the real world where every day, patients claim to be suicidal so they can be admitted to the hospital; where they claim to have ADHD so they can be prescribed Adderall; where they feign 'voices' so they can qualify for state medical insurance and housing; where they claim to be very anxious so they can be prescribed Xanax even as they are falling asleep in my office; where patients who have just smoked meth claim someone "put it in my coffee;" where they say they are too depressed to work (and are given Social Security disability for that) and yet take trips around the world to go hiking; etc, etc, etc. I could go on and on and on. Unfortunately, like most that come from outside the medical profession, your understanding of what doctors and nurses and therapists and med techs actually do every day is limited.

Why are we talking about this anyway?

fromtheFUTURE_deleted said:I live in the real world where every day, patients claim to be suicidal so they can be admitted to the hospital; where they claim to have ADHD so they can be prescribed Adderall; where they feign 'voices' so they can qualify for state medical insurance and housing; where they claim to be very anxious so they can be prescribed Xanax even as they are falling asleep in my office; where patients who have just smoked meth claim someone "put it in my coffee;" where they say they are too depressed to work (and are given Social Security disability for that)
I have never heard a less objective and more cynical practitioner in my life. Your claim that people receive disability who "say" they are depressed is laughable. People who cannot even breath without the aid of an oxygen tank have a hard time getting disability.

http://www.nytimes.com/2007/12/10/us/10disability.html

In the hospital where I work, we train our doctors and nurses to exemplify the kind of medicine that can be achieved by treating patients with care and respect. We also have some doctors like you, that are burnt-out, bitter, difficult to work with and add nothing to the patient's well-being. We do our best to get practitioners like yourself out the door. If ANY one in our psychiatry unit spoke like you just did, they would face a review before our quality control panel.

Have your friends neg me all you like. That you could claim to have any objective view on fibromyalgia or any other complex disease is disturbing. Based on your username, I am going to guess that you have not been in the field long. That you already have such a disdainful view of your patients is a bad sign.

And we are talking about this because your worldview did not allow you to follow the instructions of the moderator.

Cynical people tend to be the experienced ones. You are either not a doctor or a newbie. Give it time. It'll kick in.

Do you think that a hospital does their patients a service by taking everything they say at face value? Doctors are supposed to be critical and consider the evidence. If they think a patient is lying, they have to act on it or the condition may get even worse.

So you can run your hospital in a lovey-dovey style giving out Oxycodone scripts to any guy who had a backache. The responsible hospitals will make sure to keep drugs off the streets.

broke25engineer said:ArbolLoco said:personal responsibility?

what do you call a dealership that hands out $100,000 cars to random people without verifying income?

so stupid it should be criminal.

The dealership doesn't have to verify any income. It's in the market to make money, not to protect people from themselves.
The dealership has already cover it base by taking a $30K deposit. The MSRP of the car is around $100K, thus the deposit is about 1/3 of the car's invoice price. Since they can reprocess the car if the lady stop paying

I wish I could green this twice!

fromtheFUTURE_deleted said:
I have never heard a less objective and more cynical practitioner in my life. Your claim that people receive disability who "say" they are depressed is laughable. People who cannot even breath without the aid of an oxygen tank have a hard time getting disability.

so why is someone with a 'real' problem having a harder time getting assistance than someone with a drug habit/'fake' problem?

ifyouhavetoask said:heynoel said:broke25engineer said:ArbolLoco said:personal responsibility?

what do you call a dealership that hands out $100,000 cars to random people without verifying income?

so stupid it should be criminal.

The dealership doesn't have to verify any income. It's in the market to make money, not to protect people from themselves.
The dealership has already cover it base by taking a $30K deposit. The MSRP of the car is around $100K, thus the deposit is about 1/3 of the car's invoice price. Since they can reprocess the car if the lady stop paying


I wish I could green this twice!Car dealers don't hold the notes on the cars they sell.

If too many of the car loans originating from a dealership default, that dealer will no longer be able to obtain financing for its customers.

Dealerships care very much about bad loans. To think otherwise, is to not understand how dealership financing works.

Yes, of course the bank that actualy owns the loan is the one that is on the hook if the buyer defaults. What I meant to agree with was that businesses are there to make money, not to protect individuals.