Urte Laukaityte
Affiliation: Aarhus University
Category: Philosophy
Keywords: clinical practice, inference, symptom perception, placebo, functional neurological disorder
Date: Wednesday 3rd of September
Time: 15:30
Location: GSSR Plenary Hall (268)
View the full session: Psychotherapy & Psychiatry
There are good reasons to expect that symptom experience is an inferential process. Firstly, cognitive neuroscience frameworks that model cognition as relying on inference are on the rise. To the extent that capacities like perception are inferential, there is reason to suspect that symptom perception would be, too. Secondly, conceptualising symptom perception in this way has explanatory power. Functional neurological disorder (FND) has posed a complex challenge in medical theorising. Terms related to the phenomenon have included ‘hysteria’, psychosomatic, psychogenic, conversion, dissociative, somatoform, so on (North, 2015). Although the relevant terminological terrain is vast and not without peril, roughly, ‘FND’ refers to the state of distressing clinical symptoms not grounded in underlying physiological disease or damage (Hallet et al., 2016). The leading cognitive account involves shifting our understanding of symptom experience as a reliable read-out of potential underlying disease processes and instead viewing it as a type of inferential decision-making in the cognitive system that is prone to bias and mismatch (Van den Bergh et al., 2017; 2019). What this means in practice is that various factors influence the extent to which clinical symptoms reflect and track underlying disease in different patients at different times, including interindividual variability in personality traits (e.g. negative affectivity), personal history (e.g. trauma), cultural background (e.g. illness beliefs), contextual factors (e.g. stress), and the kinds of symptoms involved (e.g. fluctuating, multisystem, chronic). The inferential view of symptom experience accounts for the fact that there is mostly a close enough coupling between the two, while also allowing for the possibility of varying degrees of correspondence – at the far end of the spectrum lies FND with often extreme symptoms generated in the absence of disease or damage. There are also cases where the disease process is addressed but the symptoms do not subside, and those where there is significant physiological damage but little to no symptom experience. The inferential approach can account for various forms of possible mismatch.
If symptom perception is inferential, it is also easier to explain why certain kinds of placebo can be therapeutic – a phenomenon that, I argue, we should be making more explicit and targeted use of in the clinic. I view this proposal as complementary to Stegenga’s (2018) formulation of gentle medicine in terms of deprioritising interventionist methods in clinical practice as a default, instead placing greater emphasis on more cautious, less aggressive treatments. He approached the subject from the point of view of medical nihilism, i.e. the claim that the effectiveness profile of most available medical interventions is much less impressive than generally assumed. I submit that there is also another reason to consider prioritising practices in accordance with the idea of gentle medicine – the likely prevalence of some degree of symptom amplification and/or functional symptoms in patient populations. I suggest it is plausible that the two could be related, too, such that part of the reason for subpar effectiveness of certain medical interventions designed to target disease processes may be connected with the relatively high prevalence of functional symptoms of one kind or another (e.g. possibly of relevance to Kirsch, 2010). Although Stegenga (2018) centres lifestyle and societal changes vis-à-vis the gentle medicine paradigm, I believe more intentionally harnessing the placebo effect in the clinic could prove to be a fruitful addition as well. Although cases of FND are more straightforward to diagnose and target more specifically even without adopting a gentler approach across the medical system, there are likely many more patients who could benefit from greater focus on tapping into placebo-related cognitive mechanisms in clinical settings.
Notably, in recent years the conception of placebo has been expanding beyond particular methods like sugar pills, saline injections, sham surgeries, and others typically associated with placebos. Under this more expansive view, it is not the means itself, but rather the psychosocial context of the clinician-patient interaction and the therapeutic ritual that comprise the key ingredients for the potency of the placebo effect (e.g. Barrett et al., 2006; Miller, Kaptchuk, 2008; Miller et al., 2009; Kirmayer, 2016). In line with the viewpoint of a clinical encounter as a form of ritual, Hardman, Ongaro (2020) put forward a call for what they term subjunctive medicine. The argument proposes reconceiving the encounter as a co-construction of ‘temporary shared social worlds for a particular purpose’ (Hardman, Ongaro, 2020: 3). The authors characterise this process as subjunctive in the sense of dealing with alternate possible worlds, narratives, virtuality, and imagination to invoke the notion of possibility and hence facilitate transformation from sickness to health. They claim that modern medicine needs to shift from focusing solely on the physical body to including considerations of what they call ‘the lived body’ to ‘expand opportunities for healing’ (Hardman, Ongaro, 2020: 6). To motivate this claim, Hardman, Ongaro (2020) explicitly reference the prevalence of functional symptoms as well as the efficacy of placebo and ritual. Relatedly, there has been work implicating psychological flexibility as the hallmark of health (e.g. Kashdan, Rottenberg, 2010). For instance, Hinton, Kirmayer (2017) develop an account, according to which healing is intimately tied to flexibility and effective healing practices will tend to revolve around symbols, images, metaphors, and acts that promote a sense of possibility and openness to a different way of being-in-the-world. Modulating focus and attention is crucial in enabling transformation of this kind in a healing context. Importantly, there is no denying that biomedical interventions are critical in targeting disease, yet I maintain the psychosocial context is not currently emphasised enough, despite its potential to significantly improve patient outcomes. For example, note that the potency of many drugs and other interventions known to be effective drops considerably, if the patient is unaware they are receiving the treatment (Benedetti et al., 2011). In order to be helpful, the clinician should use any relevant tools at their disposal to signal the possibility of change as a means of enhancing the curative properties of any clinical regimen. I draw out some concrete implications of accepting that symptom perception may indeed be inferential.