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"Whiplash and Other Useful Illnesses":

I've read most of this very interesting and entertaining book, written by Toronto psychiatrist Andrew Malleson. I'm not sufficiently familiar with the scientific literature to vouch for his conclusions, and there are places in the book where Malleson seems to me to go well beyond his own expertise and reach conclusions that are not directly supported by his evidence. Indeed, I think the book would benefit from being edited down by about a third, with the weaker and more speculative material deleted.

Nevertheless, there are many useful tidbits of information and startling hypotheses in this book, with sufficient citations to the academic literature that the reader could look up the relevant studies for himself if he is skeptical. This is certainly a book that should be on the shelf of, among others, (a) anyone who represents insurance companies in automobile accident injury litigation; (b) anyone interested in "junk science" in general; (c) anyone interested in how the medical profession, or elements thereof, sometimes creates official "illnesses" that are really just clusters of symptoms with no common or known physical cause; (d) anyone interested in the effects of litigation on accident victims, and whether the victimization that are required to exhibit for legal purposes may hinder their emotional and physical recovery; (e) anyone interested in somatic illnesses; (f) anyone interested in malingering and fraud in the workers' compensation and tort systems; and (g) anyone interested in how the legal system encourages, profits from, and sometimes precipitates (c).

Perhaps because the book was written by a Canadian and published by a Canadian press, it hasn't received much attention from American legal scholars since its initial publication in 2003; indeed, it has only been cited once on Westlaw so far. But the book provides abundant material to inform debates on a host of legal issues.

Chris Bell (mail):
I have gotten "whiplash" from a sudden rear-impact car crash.

It hurts!
4.14.2007 11:38pm
davidbernstein (mail):
The author doesn't deny that people get neck and shoulder pain from accidents. He denies that the pain last for nearly as long as it does for nearly as many people as it does.
4.14.2007 11:45pm
Reg (mail):
How about fibromyalgia, does he have anything to say about that one? Call me insensitive, but it seems like it afflicts mostly depressed women looking to collect disability. "Ow, my trigger points!"
4.15.2007 12:03am
JB:
4.15.2007 12:30am
davidbernstein (mail):
He has quite a bit to say about fibromyalgia, which he believes doesn't exist except for legal purposes.
4.15.2007 12:35am
neurodoc:
He has quite a bit to say about fibromyalgia, which he believes doesn't exist except for legal purposes.

Fibromyalgia is not a bona fide physical illness, but rather a "diagnosis" that only attaches for "legal purposes"? Help me then to understand how it is that credible medical specialists, especially rheumatologists, offer that explanation ("fibromyalgia") for individuals who are not and will not be plaintiffs in a lawsuit, disability seekers, etc.?

I have always been skeptical about this entity which has rather "soft" diagnostic criteria and no unequivocal, entirely objective findings, especially since it is often a component of otherwise suspect injury claims. I am not persuaded, though, that "fibromyalgia...doesn't exist except for legal purposes." And DB, perhaps you shouldn't be so credulously accepting of a psychiatrist's testimony about the presence/absence of "organic" illness. (BTW, does Dr. Malleson testify on behalf of defendants in personal injury cases?) Now, if you want to go after something that is bogus to the core, take "multiple chemical sensitivities."
4.15.2007 2:09am
neurodoc:
Amazon quotes from a review of this book (not an "editorial review," which would carry much more weight) in the New England Journal of Medicine, "Malleson writes with a self-admitted bias from years of working as a defense expert in legal cases involving whiplash and other illnesses for which patients may be compensated." I see no mention in that book review, nor in the others excerpted by Amazon anything about "fibromyalgia," so I don't know the details of what Malleson thinks about that condition, except for your report of his ultimate conclusion about it.

BTW, what "weaker and more speculative material" do you think should be deleted?

I have advocated/recommended in various settings compensation for those I believed on the basis of convincing evidence had physical problems that they deserved to be compensated for, and I have advocated/recommended against compensation for those who had no such evidence. Your (a) through (g) are appropriate enough, but there is an unfortunate lack of balance when all the attention goes to plaintiffs and nothing is said about less than honest medical/scientific defenses argued by defense attorneys on behalf of their clients. (Is "ho" acceptable here? If so, I will say there are both plaintiff ones and defense ones out there, especially in the medical malpractice arena.)
4.15.2007 2:31am
Another Doc:
Fibromyalgia, and any number of other "diseases" exist, not for "legal" purposes, but because of third-party payment mechanisms in the United States. Before, one could examine a patient, run tests, say, "I'm sorry; I'm sure you're in a lot of pain but the tests show nothing." Then insurance wouldn't continue to pay for continued visits and continued tests. But once a CPT code is created the doctor can now say "You've got fibromyalgia. See me again in two weeks." and the doctor gets paid. That's how diseases are multiplied in an era when the goal is to justify payment requests to insurance companies rather than demonstrate a value worth paying for to the patient.

In addition, giving "nothing's wrong with you, you're just complaining about pain" a Latin name allows people to qualify for disability, take off work with pay, etc. It's an not unexpected consequence of laws designed to help people who are sick by forcing others to compensate them. At the margin, more people become sick. I'm sure neurodoc sees this in his practice, as I do in mine.
4.15.2007 2:58am
Bob Flynn (mail):
anyone interested in how the medical profession, or elements thereof, sometimes creates official "illnesses" that are really just clusters of symptoms with no common or known physical cause;

Amazingly, this describes the disease called "AIDS" which has scared people for 26 years. It really is just an umbrella designation for 20 or so old diseases (tuberculosis, pneumonia, yeast infection, diarrhea etc).

See, Dr. Peter H. Duesberg
4.15.2007 3:45am
Henri Le Compte (mail):
Just adding my voice to the chorus of other docs here. Diseases like "fibromyalgia" are just simply poorly conceived, umbrella diagnoses. For example, almost certainly a sizeable chunk of patients with that diagnosis are depressed. Another segment are chronic somatizers. And another are just malingering.

The problem is that, as sophisticated as medicine is, we don't have perfect knowledge of the human body. Syndromes that involve chronic pain are frustratingly complex. And... none of that is help by the numerous ways in which our generous society "rewards" people for being sick or disabled. In my opinion, the majority of people that I have seen with the diagnosis of "fibromyalgia" were clearly malingering. Either for some sort of disability payments or for pain meds. Over time I have come to be pretty skeptical of that diagnosis.
4.15.2007 10:17am
Ella (www):
For the Doctors - Do you think that fibromyalgia, CFS, etc. also exist in part because of the traditional aversion to treating (or paying for treatment of) depression as a medical disease, both on the part of insurers and patients? I have a few family members who have beeen treated for fibromyalgia. None seem to be malingerers, nor have they attempted to get disability, nor are they on pain medicine more powerful than prescription anti-inflammatories (there was much grief in the family when Vioxx was pulled from the market). Some have also been treated for depression and arthritis, for which there is a family history. Invariably, the fibromyalgia dx predated the depression dx by several years. It seems that even - or perhaps especially - for very educated people it's more acceptable to label a problem "fibromyalgia", which makes it sound like a somatic problem, than "depression", which makes it sound like it's all in your head. Since the treatment for fibromyalgia includes antidepressants, it seems like a dx designed to get a patient to accept appropriate treatment without having to fight her attitude about depression.
4.15.2007 11:32am
anonymous coward:
Like neurodoc I'd like to know what material DB thinks should have been edited out.

And what's the solution? Binding arbitration?
4.15.2007 12:17pm
davidbernstein (mail):
(1) Unless you've actually read the book, or are planning to read it presently, what purpose would it serve to tell you which parts I found less persuasive?

(2) To reiterate, I don't know enough about the scientific literature to endorse the author's conclusions. But he raises enough provacative questions with citations to, and quotations from, the medical and scientific literature, that the book is well worth reading even if he not always right.
4.15.2007 2:04pm
L.J.:
McGill-Queen's is actually a really interesting and unique university press, for those who pay attention to such things. See Nathanson &Young's Misandry books.
4.15.2007 9:22pm
visitor from Texas (mail) (www):

Just adding my voice to the chorus of other docs here. Diseases like "fibromyalgia" are just simply poorly conceived, umbrella diagnoses. For example, almost certainly a sizeable chunk of patients with that diagnosis are depressed. Another segment are chronic somatizers. And another are just malingering.


But, there is a cluster of people who suffer from such, and knowing what the genesis is, treatments such as antidepresents and rophanal, are easier to understand.
4.16.2007 6:58pm