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Notes -
On fakes and faking:
There are a few interesting patterns I’ve seen regarding discourse around certain things being “fake,” or that certain people are “faking” or have “faked” something, wherein one finds distinct claims being either accidentally mistaken or deliberately conflated. And while there are definite culture war examples — sometimes in multiple areas — my initial examples are going to be less so.
[1.] “Person X is faking (very real) condition Y” versus “Condition Y is fake”:
A notable fictional example is in the South Park episode “Le Petit Tourette,” wherein Cartman fakes having Tourette syndrome to get away with randomly swearing. To quote from the Wikipedia summary:
[2.] “Condition X is fake; those who claim to have it are perfectly fine” versus “Condition X is fake; those who claim to have it actually suffer from Condition Y”:
Here, my example is Morgellons. I remember one memorable comment online from a doctor (back when I first encountered this particular internet rabbit-hole), responding to one “Morgellons” sufferer’s claim that doctors ‘refuse to give them a diagnosis,’ that no, doctors have been giving them a diagnosis, the same diagnosis, over and over: delusional parasitosis.
[3.] “The video/book is fake, as in staged” vs. “The video/book is fake, as in nonexistent”:
Here, examples of the first are any “mockumentary” or “found footage” movie — i.e. “The Blair Witch Project” is fake. This is the sort of claim that moon-landing conspiracy theories make. The second example, in comparison, is saying that something is fake like the way “Goncharov” is a fake movie — it doesn’t actually exist, and anyone who claims to have watched it is lying (in the case of “Goncharov,” as part of the game/fun.) Generally, what I see here in terms of ambiguity/equivocation is someone making a claim of the second type which people then “debunk” as if they had made the first type of claim.
Thoughts?
I think #2 tends to conflate two different phenomena for me. There’s “these people don’t have a disease” could mean one of two things. Either they have no symptoms, or no unique symptoms, or they have symptoms but has no actual pathology. I think the second one is a bigger problem in the west than the first. We seem to have a mania in America and the west of codifying everything that’s uncomfortable as some sort of mental illness or disorder. I think this is hugely reductive of the human experience where people can be distressed for all kinds of very valid reasons and that these reasons go away when the underlying causes are dealt with. You can be depressed because of your life circumstances, a death, a bad job you can’t escape, loneliness, and a whole bunch of other things. But I don’t think those are necessarily pathological mental disorders. In fact I think a case could be made that in certain circumstances not being depressed is pathological. If you were falsely imprisoned in poor conditions and no hope of release, the natural response is absolutely depression, and not being depressed is pathology.
I think we’ve generally done a very poor job of creating resilience in our population. And I think this not only drives normal people to seek help for minor things that would be better fixed by fixing the underlying issues. It also, by not fixing the issue when it’s small and fixable permanently gives people an illness. Three years after the person starts feeling sad because they hate their life, if nothing changes and they don’t learn to cope, they likely will be actually depressed. And then you have a mental illness for a very long time.
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The brain is an organ so obviously all psychiatric conditions (including “chronic fatigue syndrome”, “long COVID” and so on) are real medical conditions.
Rather, the term real or fake in this context typically serves to delineate conditions from which one could immediately recover if one’s psychological status altered favorably (however unlikely) from those from which recovery is not dependent upon psychological condition, like having your legs blown off in a bomb or dying from Ebola.
It is my firm belief that people with severe psychiatric disorders that appear to be permanent should essentially try the kitchen sink of pharmacology and related lifestyle alterations. Drop acid, try ayahuasca, stay at a Buddhist temple and meditate in silence for three months, change your diet radically, fast, don’t fast, exercise, try every kind of antidepressant, stimulant and so on, whatever.
But it must be acknowledged that these are only options precisely because an actual, biological ‘road to an early death’ (from an actual, physical medical condition that must be treated) is not guaranteed in all but the vaguest sense (like that mentally ill people lead generally shorter lives).
As @self_made_human says, a lot of sufferers of psychosomatic conditions are happy to hear that their bodies are healthy because it means they’re (probably) not going to get seriously ill or die very soon. This illustrates how bullshit the attempts by whiny sufferers of psychosomatic conditions to compare their situation to that of people dying from cancer or dealing with lifelong terminal health conditions actually are.
And I think that’s what annoys people in this aspect of the ‘real’ vs ‘fake’ debate. Being tired and fatigued for 10 years (but otherwise having decades of life left to live) isn’t the same as dealing with a terminal condition. I like life, and with (very) few exceptions I would rather live a worse life than die.
You should probably separate out things like depression and anxiety from illness like bipolar and schizophrenia. Some (considered crackpot) physicians will try and manage bipolar with therapy or recreational drugs but schizophrenia is pretty much straight up well understood pathophysiology that 100% necessitates medication management.
The stuff that can be managed conservatively rarely catches a diagnosis in those cases which does admittedly complicate the issue.
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An issue here is that what people are exposed to mostly actually is "fake" (or mild) because it's mostly those people who have the energy and resources to advocate for themselves (or promote in the case of grifters). This goes for a ton of things, like autism. How much are you exposed to the mildly autistic nerdy guys and how much to the non-verbal people who need to be supervised and/or restrained 24/7 to prevent them from eating their own shit and stabbing themselves with sharp objects? (Actual example from my time working as a home carer).
How many people eating gluten free have celiacs and how many are just pretentious assholes?
How much is one exposed to the whiny Redditor/TikTok long covider and how much to the person who is about as functional as someone in the last week of their life with terminal cancer? I don't think anyone whose seen the latter in real life can believe it's fake or even psychiatric but people don't see that, how could they realistically?
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I am convinced, beyond reasonable doubt, that psychosomatic disorders are real.
So are the overwhelming majority of doctors.
In the majority of cases, this is not a problem for the patient. In fact, a lot of the time they're happy that the miscellaneous aches and pains that plague them are not indicative of a more serious condition, and can be dispelled with a combination of reassurance/therapy/antidepressants/neuropathic drugs.
This does not always work. Quite often, patients are unhappy/depressed for eminently sensible reasons that are beyond our, or their, ability to fix. The catch-all term for this, at least in the UK, is "Shit Life Syndrome". The prognosis is often terminal.
On the other hand, we have the Munchies, the 'ol sufferers of Munchausen syndrome, or worse by proxy, where some other poor bastard, be it a child or elderly relative unable to speak up for themselves, is subject to their torments.
They certainly are less than happy to be caught, even less happy about being treated for it, and unfortunately, in most cases, can't be committed involuntarily, only duly ignored in the future. Of course, if a case of abuse can be brought against them on behalf of those in their care, all the better.
And there are all kinds of hypochondriacs who aren't happy unless taking at least three medicines a day. On the plus side, they're quite scrupulous about it, which is more than I can say about many people who need them more.
Are there false positives and negatives? Undoubtedly. Someone, somewhere, is going to have a legitimate disease, likely an obscure one, and their concerns dismissed. But make no mistake, such incidents are in the firm minority. Most people who are dismissed by multiple doctors are dismissed because there is little that can be done, or nothing to do in the first place beyond tell them that they don't have what they're convinced they have.
This is one of the more striking things about the various sorts of mystery syndrome people that firmly believe they're being pushed off for no good reason. They don't seem to be able to adequately model the minds of physicians. What do they imagine that physicians get into medicine for? What do they imagine the typical physician would like to do for their patients? Of course, it is true that some physicians will become so severely jaded that they're really not doing a very good job of looking at individual patients as individuals, but this is not my experience with the vast majority of physicians across different disciplines. Even the docs that specifically avoided working directly with patients (pathologists, molecular geneticists, other lab-types) are deeply, personally invested in doing what they can on a day-to-day basis to heal people. When a pathologist bumps into a weird section that isn't consistent with reported clinical indications, the response isn't, "well fuck 'em, I have other things to do", it's grabbing a colleague to figure out what IHC to order, what genetic diseases they haven't considered, and so on. OK, it's not like House on TV, but medical staff really do make a pretty substantial effort to nail differential diagnosis.
So, yeah, if multiple doctors at different institutions are dismissing you as actually biologically healthy, the likelihood really is that you're just a hypochondriac.
Bang on.
I've met jaded and burnt out doctors going through the motions, even dangerously incompetent ones. But they are a small fraction of the ones you'll encounter.
Doctors want to be able to pin a diagnosis on you. We want our patients to recover and get better. It certainly helps with billing insurance if nothing else.
In the absence of strong evidence to the contrary, my default presumption in such cases are that there's nothing wrong with the patient, or nothing that can be solved by giving them the diagnosis they desire.
It doesn't help that it's the odd case where someone legitimately fell through the cracks that is overwhelmingly likely to be signal boosted.
"Doctor diagnoses man with dyspepsia as having H. pylori infection, eradication regime succeeds, problem solved" is dog bites man news. Them missing a case of stomach cancer isn't, especially with anecdotes of the Herculean struggle by the poor sap to remedy that scenario.
This is not to dismiss all complaints as illegitimate, India suffers from a serious paucity of awareness about mental illness, both in the lay population and doctors (ahem, my adult diagnosis of ADHD, which should not have required me to have been an adult to receive it, especially since my parents are MDs). But that's for well-recognized, or rather well established but under-recognized diseases. If someone organized a Fibromyalgia awareness campaign here, I'd join in lynching them.
It's possible you had a bad doctor. If all the doctors you've met have been awful, it's the asshole-in-the-room thing again.
I think a reason a perception of lazy and uninterested doctors you have to fight with in order to get (the correct) treatment sometimes persist is because the first point of contact for many are GPs and GPs often are the bottom of the barrel of doctors and the most jaded and working under unreasonable time constraints since they act as gate keepers to the rest of the medical system.
Once you actually meet a specialist its like another world. People are (generally) interested, competent and trying to help.
Competent and sympathetic GPs of course do exist but many (most in my impression honestly) really are quite bad, people who either couldn't hack it elsewhere, incompetent immigrants of dubious credentials and people who've just checked out. If anyone's on the AI chopping block it's these guys.
If thats who you're mostly interacting with then what is your impression going to be?
I resent being called out specifically in this manner /s
Thankfully standardized testing indicates I am above average in my equivalent cohort of GMC registered doctors.
GP, now that's going to vary from place to place. But I know the ones in the UK are severely overworked and the official amount of time allocated per patient can be as low as ten minutes, 15 is generous. Even if they would love to take their time, they simply don't have it, and they are forced to implicitly reallocate from the clear-cut cases to the ones who really need it. I would love to defend them against accusations of being bottom-barrel doctors, since someone needs to do their job, but let's just say that with my MSRA score if I had wanted to be a GP I'd be one already, instead of being strung along with further rounds of psych placements. It's hard work, with additional medicolegal risk from seeing such an undifferentiated patient pool. You have the stress of this seemingly relatively clearcut diagnosis being the one that sinks you, or at least puts you through the GMC wringer. However, GP is a great option for those unwilling to take the bullshit that is UK speciality training. Just 2 years. A great qualification if you want to flee to fairer pastures. More scope for private practise, and you can quickly make a name for yourself, even if it's by being just better than the awful ones.
In India, any doctor post MBBS is a GP. It's not a protected specialization like in the UK. And anyone worth their salt will join the rat race in an endeavor not to stay that way. However they don't fill the same niche as gatekeepers as in the UK, patients will usually book appointments with the specialist they (think) they need, or be summarily referred to one. The first port of call for most is a General Medicine doctor (or a super specialist who still sees such cases), and that only comes after a competitive 4 year MD.
Elsewhere? Can't comment. Maybe @Throwaway05 might have something to add. Or @Pigeon from even further afield.
Being an excellent PCP is possibly the most difficult and cognitively demanding job in medicine. On top of that pay is shit, prestige is shit, so great people don't go into it but great people are needed.
Corporate pressure and increasing health problems means they have less time with patients but more to do than ever before.
It's a mess and I understand why patients feel mistreated but they also have no idea whats going on.
As for the specifics in the U.S. IM or FM can be a PCP after completing a relevant residency, with (some?) states having a process for being a "GP" with more limited scope of practice after completing certain levels of residency.
The U.S. is weird because all docs can technically do anything in medicine (unrestricted practice) but getting permission to do that in a particular facility, malpractice insurance, and getting patient's insurance to cover what you do is all complicated. Certain kinds of ethically challenged people manage.
In the UK, the pay is thankfully not shit. Well, by your standards (and mine) the pay for most doctors is trash, but GPs reach those hallowed plateaus faster than other fuckers slogging through 7 years of training.
I think the Indian system is quite similar to the US. I know of scenarios where there are legal requirements, such as it taking a psychiatrist to prescribe stimulants, but it's a combination of getting no
bitchespatients and the medicolegal concerns you mentioned that prevents anyone from doing just about anything.I have heard some stories about the antics of my colleagues in more rural areas. I can't relay them on a public forum without contacting my lawyer first, even if I'm not involved. It gets that bad.
It's not unreasonable for a PCP to make 180-220 a year. That's a lot of money in comparison to most jobs, but when the surgical sub specialist is making 600-800.....people follow incentives.
Note: We have orders of magnitude more doctors in primary care than the sexy big number specialties.
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We don't get many Indian doctors here, it's mostly middle eastern ones and some from eastern Europe. It's usually the middle eastern ones that are the problem, with the Persians being a big exception.
The funny thing is that immigrants with specialisations are easily as good as the natives, and often better, while their GP co-ethnics are mindbogglingly incompetent.
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I feel like this misses the case where the "real" and psychosomatic overlap.
There are some conditions that are "real" but rare and their "popularity" far outstrips the rate of the sufferers of the "real"/"physical" condition. Here we have things like various exotic mental disorders/syndromes, pain conditions, digestive disorders, allergies, fatigue conditions (most recently long COVID), auto immune disorders and transexualism.
Also, people who have the conditions likely have some of the conditions that causes psychosomatic symptoms similar to the condition, often because the condition itself causes or encourages behaviour leading to depression, anxiety, inactivity and or isolation.
How does a doctor tell whats going on? How does the social security system? How does the general public? How does the person themself?
As soon as something like this goes mainstream it inevitably gets dragged down in partisan politics.
I don't get paid nearly enough to get dragged into the debate on Fibromyalgia, Long COVID and the like. Especially the latter.*
But, for what it's worth, I have never seen a case of fibromyalgia in India, and even googling for cases here turns about zilch. On the other hand, sequelae after a severe viral illness is quite common, and whether or not COVID deserves a specific carveout is something I don't have a strong opinion on.
Make of that what you will.
*It has come to my attention that I don't get paid at all, but if someone wants to rectify that, Google the BMA rate card. And that does not include the 500% hazard pay rates I demand for trans medical care, or opinions on that.
My suspicion is that this is a trans type situation. Yes there are real trans patients. Yes there are cultural contagion trans patients. Yes there are borderlines (and others) with identity instability manifesting as trans thought character.
Likewise with Long COVD et al you have a mix of those pathologies being rolled together and it really reduces clarity and makes it unclear to what extent it is a real thing. Some people likely do have mangled CNS/PNS as a result of viral illness, others are maybe looking for a more ego syntonic expression of their depressive symptoms.
I know less about fibromyalgia but my understanding is that some physicians are emphatic it's a real thing and more investigation will make real bio markers or whatever abundantly clear.
Not seeing any fibromyalgia in India is interesting but its possible that it's in some way culture-bound, or environment-bound - higher parasite burden, rougher lives may prevent the sensitization or whatever else is going on under the hood.
There was a study done of "long COVID" which demonstrated that the only symptom of long COVID patients that was correlated with actually having tested positive for COVID at some point was loss of taste and smell. So yes, there are real and there are fake, but there's a whole lot more fake than real. And I suspect the same is true of trans patients. A few have a mental illness specific to that (call it "gender dysphoria" or whatever), a large number have cluster B personality disorders, and an even large number are pure social contagion.
I don't know if I believe in such a thing as long COVID, I do think that some people have gone online to make a whole condition out of post-viral syndrome and the like.
But Trinity College Dublin is at least half-assed respectable, and their eggheads are claiming that something is going on with leaky blood vessels?
Newspaper report here, link to published paper here. Again, I have no idea if Nature Neuroscience is a reputable journal or one of those 'you pay, and we'll publish any old rubbish" efforts. But the bit about serum from patients with (alleged) long COVID producing inflammatory markers in cultured cells would seem to indicate that there is indeed something there:
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Identity instability is a literal symptom of borderline. Not surprising if these people (when unstable) have trans thought content. If you throw the long COVID equivalent into your research studies, it's going to give you a ton of junk data and hide whatever thing is really going on.
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Great, a comment refresh ate everything.
But here's two screenshots of my Google results, I suspect yours would look very different.
https://ibb.co/cwqnt5K https://ibb.co/Bcxb3Jr
It's not that there's precisely zero fibromyalgia here, but I've never seen it diagnosed and don't know of a diagnosis through at least two degrees of separation. Old research papers, legitimate and more sketchy clinics advertising, pure puff pieces. One article from 2014.
I also can't recall formal diagnosis of Long COVID here either, and believe me I've treated more than my fair share of COVID patients, and everyone and their dog has caught it. I have seen symptoms that could be attributed to it, or at least COVID serves as the best proximate cause.
I would guess a culture of "toughing it out" and "oh god we have tons of real health problems" limits the role for these softer diseases.
Also thank you for introducing me to "crore."
Trust an American to show appreciation for non-standard and awkward methods of counting! I'll take millions any day, as a matter of fact I mentally convert from those to crore rather than vice versa.
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In context, people talking about conditions being real are talking about them actually being physical conditions. Delusions aren't "real" in this sense. It's true that you can claim "it really is a delusion" or "delusions are real things, see, we can describe what a delusion is" but that's not what "real" normally means and claiming that the condition is still "real" because it's a real delusion is sophistry.
True, but there's still a difference between "this person suffers from a delusion" and "this person is deliberately lying for attention."
Another, more culture war example, is the people who identify as "plurals." They aren't claiming to have a physical condition, but one that is just as much "in their head" as any delusion — they are talking about having "headmates," after all.
Let's add a third category - someone that really did have transient symptoms from something that were unpleasant and difficult to explain, then that manifested as a long-run delusion that the underlying cause was still there. I find this entirely plausible based on personally having experienced a few things that were genuinely unpleasant, I received no medical treatment for, and that went away on their own. As a non-worrier, I generally do my best to just not think about it too much and figure it'll resolve, but I can easily imagine how someone that is a worrier could believe they're on their way to death and have that spiral out of control.
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I don't think there's much of a difference, though. One of the most common techniques that people use to deliberately lie for attention is to genuinely believe the lie before repeating the lie to others. This is a very clever way to avoid any of the guilt or shame that many/most people experience when they deceive people, while getting all of the benefits of being deceptive. Lying to oneself so well that one believes the lie is pretty much the same thing as deluding oneself.
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Almost all the headmates/tulpa nonsense is faking for attention, I'm sure there are some genuinely real schizos in the mix but "hearing-voices-schizophrenia" is so rare in young adults that most of them have to be bullshitting.
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