Authors of our own misfortune? The problems with psychogenic explanations for physical illnesses

Authors of Our Own Misfortune is an innovative and stimulating work which considers the conceptual basis and methodological flaws that inform psychogenic explanations given to patients with medically unexplained symptoms. In a comprehensive review of the literature on psychogenic explanations for physical illnesses the text provides a welcome critique of current medical and scientific paradigms that often result in serious adverse effects for patients given a psychogenic diagnosis, such as chronic fatigue syndrome (CFS) and myalgic encephalomyelitis (ME).

Kennedy argues that psychogenic explanations for physical illnesses are rooted in faulty logic and moralistic belief systems which situate patients with medically unexplained symptoms as deviant, bad and malingering. The diagnosis of a psychogenic disorder often has detrimental consequences for these patients as they are stigmatised and denied adequate support because of the contested nature of their condition and the value judgements attached to it.

The construction of psychogenic explanations is examined in the first part of the text. The work begins by defining the key terms and the multiple synonyms used to refer to ‘psychogenic’ explanations. Broadly, ‘psychogenic’ refers to physical symptoms which are presumed to have a psychological cause as opposed to being part of an organic disease process. The myths used to justify psychogenic diagnoses are considered in Chapter Two – if a somatic illness cannot be explained within current medical knowledge it is assumed to be psychogenic in nature. Kennedy disrupts this seemingly objective medical basis of psychogenic explanations. Circular reasoning is highlighted as a methodological flaw in relation to research and clinical investigations of psychogenic illnesses which perpetuates these myths. The example of research into CFS is used to illustrate this because cohort criteria which exclude patients with physiological abnormalities preserve the cause of CFS as determinedly psychological.

This argument is built upon in Chapter Three, which considers the ways in which psychogenic explanations are constructed and bolstered through the psychopathologising of a patient’s benign characteristics. A patient’s personality, their responses to impairment and even their social stratification are often considered indicative of a psychogenic explanation, and thus reinforce the diagnosis. There is an affinity between this section and that of Campbell’s (2013) genealogy of the diagnostic category of dyslexia, which considered the pathologisation of certain characteristics over time in accordance with moral judgements. Therefore, this section is recommended to those interested in the sociology of impairments and the construction of diagnostic categories within the field of disability studies.

Chapter Four examines three specific problems with psychogenic explanations (stress, CFS/ME and the placebo effect). Using these examples, methodological and conceptual flaws are examined; Kennedy reinforces her argument that medical research in relation to psychogenic explanations cannot be considered value-neutral. The negative perception and value judgements attached to patients who are given psychogenic explanations are considered in Chapter Five. The author asserts that patients with a psychogenic diagnosis are often constructed as ‘deviant’ and characterised with negative value judgements in medical discourse. This chapter makes interesting connections with the concept of ‘the sick role’ and how patients with psychogenic explanations are assumed as malingering.

The second part of the book moves on to look at the adverse effects these presumptions and values have on patients given a psychogenic diagnosis. Cognitive behavioural therapy and graded exercises training as treatment options for CFS/ME are critically evaluated in Chapter Six. The ‘fallacies’ and value judgements attached to psychogenic conditions discussed earlier in the text are shown to limit the available research and thus the treatment options available are ineffective with harmful effects for patients. The adverse effects that psychogenic explanations can have on patients are considered further in Chapter Seven. These include misdiagnosis (associated with psychogenic dismissal), physical harm, fatalities, social exclusion and stigma. Kennedy argues that psychogenic explanations can be seriously harmful for patients. At points this chapter is difficult to read, particularly when recounting the examples of institutional abuse that patients with psychogenic diagnoses have experienced. Hidden experiences of abuse and stigma by the healthcare, education and social service professions are elucidated. Kennedy makes clear that these experiences are the result of the negative assumptions, myths and false characterisations of psychogenic explanations. The conclusion is a call for those in the social sciences, the medical profession and lay media to think critically about the malignant moral and ideological attachments to psychogenic explanations and challenge these perceptions.

Authors of Our Own Misfortune is a useful resource for those interested in medical sociology, those working in the healthcare profession and those within disability studies interested in the sociology of impairments. Equally, as someone who has previously been given a psychogenic diagnosis, I found Kennedy’s writing enlightening and empowering. This text would be beneficial for patients; although some parts make for difficult reading, particularly the details of abuse, it is important that these experiences are told so that they can be challenged.

In a similar way to Altermark (2014), this work contributes to research in Disability Studies which makes it clear that medicine and science are not value-neutral, but are intimately connected with politics and the moral economy. The analysis of psychogenic diagnoses (often absent in disability studies and sociological literature) provides an excellent case for unpicking the ways in which power and knowledge are deployed in the construction of impairment categories, with often problematic, stigmatising and disabling results. In this context, the analysis in certain parts could have been further enriched with more theoretical analysis, potentially synthesising Foucauldian concepts of power, knowledge and government. Notwithstanding this, Kennedy’s work provides a thought-provoking analysis that considers the stigmatising and disabling elements of the medical profession, and the ways in which some impairments can come to be deemed more acceptable than others.

Sarah Troke
University of Leeds, Leeds, UK
[email protected]
© 2017 Sarah Troke
https://doi.org/10.1080/09687599.2017.1321239