Is it Psychosomatic? - An Inquiry into the Nature and Role of Medical Concepts

Medical diagnoses define the possible modes of being ill from the medical point of view. Medical diagnoses are theoretical concepts that gain their meaning as a part of the prevailing medical theory. As medical theories change over time, also medical concepts change, as can be seen in the long history of medical thinking. The purpose of this essay is to illustrate medical thinking through examining the formation and use of one example of a particular medical concept “psychosomatic” in medical theory and practice. The approach taken in this essay reflects the writings of Lev Vygotsky, who argued that scientific concepts are tools for scientific thinking. Since all conceptual tools have their own developmental history, to understand the content of any scientific concept to the full we need to understand the processes leading to adoption of that particular concept for scientific inquiry at that particular moment in history. Vygotsky’s approach for analysing the development of science through analysing its concepts is reflected to the writings of Kuhn and Fleck on the development of science. It is argued, that Kuhn’s theory does not apply to the development of medicine. While Fleck’s approach seems to fit better to analysing the theoretical development in medicine, it remains somewhat superficial in analysing the nature and role of concepts in medical thinking. The use of medical concepts in medical practice is discussed in the light of Mikael Leiman’s ideas on the therapeutic encounter as a dialogical process. While Leiman also draws from Vygotsky he takes the issue further toward semiotic understanding of clinical dialogue by using Bakhtin’s and Voloshinov’s ideas of the semiotic nature of human communication

Impure placebo as an unsound concept and other problems in the paper by Howick et al. : [Comment]

Howick et al. have reported the findings of a survey that addressed the use of placebos among primary care practitioners in the United Kingdom. They adopted methodology similar to that used in previous studies performed in other countries; however, the use of this approach also means that they repeated the conceptual confusion of the previous surveys. Therefore the findings are not useful. ... The paper’s main finding “placebos are commonly used in UK primary care” is not correct. Only 0.9% of the responding general practitioners reported using pure placebos frequently. The frequency with which impure placebos are used is irrelevant because the concept is useless, as described above. Misleading a patient by administering inert substances without the explicit consent of the patient is unethical. The authors' proposal to “develop ethical and cost-effective placebos” is not possible because saving money by misleading patients is unethical. There is substantial conceptual confusion in the area of placebo and placebo-effect research, and the paper by Howick et al. does not help to reduce this confusion

Clinical use of placebo treatments may undermine the trust of patients : a response to Gold and Lichtenberg

There is an obvious need for a critical discussion of the concepts ‘placebo’ and ‘placebo effect’. In a recent paper on the use of placebos in clinical medicine, Gold and Lichtenberg note the conceptual difficulties but use the terminology in a confused way throughout their paper. In our response, we demonstrate these problems with a few examples from their paper.Non peer reviewe

Impure placebo is a useless concept

Placebos are allegedly used widely in general practice. Surveys reporting high level usage, however, have combined two categories, 'pure' and 'impure' placebos. The wide use of placebos is explained by the high level usage of impure placebos. In contrast, the prevalence of the use of pure placebos has been low. Traditional pure placebos are clinically ineffective treatments, whereas impure placebos form an ambiguous group of diverse treatments that are not always ineffective. In this paper, we focus on the impure placebo concept and demonstrate problems related to it. We also show that the common examples of impure placebos are not meaningful from the point of view of clinical practice. We conclude that the impure placebo is a scientifically misleading concept and should not be used in scientific or medical literature. The issues behind the concept, however, deserve serious attention in future research.Peer reviewe

Reduced tillage: Influence on erosion and nutrient losses in a clayey field in southern Finland

Reduced tillage was compared with traditional ploughing in terms of erosion and phosphorus (P) and nitrogen (N) losses in an experimental field in southern Finland. One part of the field has been ploughed (treatment PF) and the other part harrowed (treatment NPF) every autumn since 1986. Flow volume and water quality data was collected separately from surface runoff and subsurface drainage waters during 1991-1995 (surface runoff volume since 1993). Erosion was higher in PF (on average 234 kg ha-1yr-1 in drainage flow and 479 kg ha-1 yr-1 in surface runoff) than in NPF (158 kg ha-1yr-1 in drainage flow and 160 kg ha-1yr-1 in surface runoff). Total N loss in drainage flow was also higher in PF (7.2 kg ha-1yr-1) than in NPF (4.6 kg ha-1yr-1). Total P losses did not differ much; approximately 0.7 kg ha-1yr-1 was transported from both fields. Dissolved reactive P loss in surface runoff was higher in NPF (0.21 kg ha-1yr-1) than in PF (0.05 kg ha-1yr-1). This was probably attributable to the higher accumulation of P in the surface soil in NPF. The differences between the treatments were largely similar to those found in previous studies

CNS Medications as Predictors of Precipitous Cognitive Decline in the Cognitively Disabled Aged: A Longitudinal Population-Based Study

Background/Aims: Psychotropics and antiepileptics (AE) are medications commonly used among the aged with cognitive decline or dementia, although they may precipitate further cognitive decline. Our aim was to analyze the relationships between the use of (i) psychotropics (i.e. benzodiazepines or related drugs, BZD, antipsychotics, AP, or antidepressants, AD), opioids (Op), anticholinergics (ACh) or AEs or the concomitant use of two of these drugs, and (ii) the risk of precipitous cognitive decline in an older (≧65 years) cognitively disabled population. Methods: A longitudinal population-based study of general aged community-dwelling patients was executed in two phases (1990–1991 and 1998–1999) in Lieto, Finland. Fifty-two individuals cognitively disabled (MMSE score 0–23) at the 1990–1991 baseline form this study’s sample. Cognitive abilities were assessed in each phase with the Mini-Mental State Examination (MMSE) and medication utilization data were collected in both phases. The mean follow-up time was 7.6 years. Multivariate models were used to analyze the change in MMSE total score between medication users and non-users. Results: BZD or any psychotropic use was associated with greater cognitive decline in elders aged ≧75 years compared to non-users (change in MMSE sum score: –8.6 ± 7.0 vs. –3.3 ± 5.6 and –5.9 ± 7.0 vs. –2.7 ± 6.4, respectively). A greater decline was also associated specifically with the concomitant use of BZD and AP (–16 vs. –1.4 ± 7.8); as were BZD and any drug with CNS effects (–9.6 ± 9.9 vs. –1.3 ± 7.2) compared to non-users. The concomitant use of BZD and AD (–10.7 ± 4.7 vs. –3.2 ± 5.6) or ACh (–15.0 ± 8.5 vs. –3.3 ± 5.6) or any drug with CNS effects (–13.3 ± 6.5 vs. –3.3 ± 5.6) was associated with cognitive decline in patients ≧75 years compared to non-users of any drug with CNS effects. Conclusion: The use of a BZD or any psychotropic medication may be an independent risk factor for cognitive decline in the cognitively disabled aged, and patients co-prescribed psychotropic medications had greater cognitive decline. Studies with larger sample sizes and studies on possible pathophysiologic mechanisms are needed

Use of CNS medications and cognitive decline in the aged: a longitudinal population-based study

<p>Abstract</p> <p>Background</p> <p>Previous studies have found associations between the use of central nervous system medication and the risk of cognitive decline in the aged. Our aim was to assess whether the use of a single central nervous system (CNS) medication and, on the other hand, the combined use of multiple CNS medications over time are related to the risk of cognitive decline in an older (≥ 65 yrs) population that is cognitively intact at baseline.</p> <p>Methods</p> <p>We conducted a longitudinal population-based study of cognitively intact older adults. The participants were 65 years old or older and had Mini-Mental State Examination (MMSE) sum scores of 24 points or higher. The study included a 7.6-year follow-up. The use of benzodiazepines and related drugs (BZDs), antipsychotics (APs), antidepressants (ADs), opioids (Ops), anticholinergics (AChs) and antiepileptics (AEs) was determined at baseline and after a 7.6-years of the follow-up period. Cognitive functioning was used as an outcome variable measured with MMSE at baseline and at the mean follow-up of 7.6 years. Control variables were adjusted with analyses of covariance.</p> <p>Results</p> <p>After adjusting for control variables, the use of Ops and the concomitant use of Ops and BZDs as well as the use of Ops and any CNS medication were associated with cognitive decline. The use of AChs was associated with decline in cognitive functioning only in men.</p> <p>Conclusions</p> <p>Of all the CNS medications analyzed in this study, the use of Ops may have the greatest effect on cognitive functioning in the ageing population. Due to small sample sizes these findings cannot be generalized to the unselected ageing population. More studies are needed concerning the long-term use of CNS medications, especially their concomitant use, and their potential cognitive effects.</p

Plasebon ongelma

Potilaita hoitavia lääkäreitä on kannustettu maksimoimaan plasebovaikutus hoitosuhteissa. Jos tämä ymmärretään kaikkeen hoitoon liittyväksi vaikutukseksi, mitä lääkäri silloin maksimoi? Hoitovaikutusta voidaan varmasti tehostaa, mutta ensin tulisi tietää, minkälaisista elementeistä se koostuu. On todennäköistä, että hoivavaikutusta selittävät tekijä eivät periaatteessakaan ole analysoitavissa biolääketieteellisen metodologian puitteissa vain selittävät tekijät löytyvät niistä merkityksistä, jota hoitosuhteessa syntyy