Saturday, August 04, 2007

Nobel Prize in Medicine 2005: Psychosomatic Until Proven Otherwise

The discovery and proof that bacteria instead of stress causes ulcers, which won the Nobel Prize in medicine in 2005, has been cited as an example of how prevailing medical knowledge gets turned on its head. I did not realize how interesting the story is until I read the Nobel lectures and the autobiographies. These Nobel lectures, and maybe this expensive book, Helicobacter Pioneers, should be required reading for medical students. Some of the more interesting quotes are below. The story has more relevance to chronic fatigue syndrome and Lyme disease than I thought.

I was actually searching the Web for diseases once thought to be psychosomatic but eventually proven otherwise. Most of the time, Google search finds answers for me in a few seconds. This one is not so easy. There are references to all sorts of diseases such as epilepsy, multiple sclerosis, tuberculosis, and diabetes having been thought to be psychosomatic in origin, but I wanted to find a more "reputable" reference. This type of information seems to be found only in lore and anecdotes. Perhaps the medical authorities don't want to mention the history on their Web sites.

The dictionary definition of psychosomatic is "Of or relating to a disorder having physical symptoms but originating from mental or emotional causes."

In actual usage, psychosomatic is used to mean, "We don't know a physical cause or mechanism, so that means that the cause is psychological stress and anxiety, because we don't understand what not knowing is."

Despite the discovery about H. pylori in the 1980s, and the researchers finally convincing the medical community about twenty years later, and the Nobel Prize being given for it in 2005, I have still heard at least one doctor in the last year reference ulcers as an example of illness induced by stress. And here is an encyclopedia definition of psychosomatic illness that prominently describes peptic ulcer as a classical psychosomatic disorder caused by stress.

Interesting quotes from the Nobel lectures:

Helicobacter Connections, Nobel Lecture by Barry J. Marshall

To quote historian Daniel Boorstin: “The greatest obstacle to knowledge is not ignorance; it is the illusion of knowledge”. The relevance of his quotation is that in 1982 the cause of peptic ulcer was “already known”. Ulcers were caused by excessive amounts of acid secondary to personality, stress, smoking, or an inherited tendency. The successful introduction of H2-receptor-antagonists (H2RA) five years earlier seemed to confirm this idea because nearly all ulcers could be healed by lowering stomach acid secretion with these drugs. Thus, when Helicobacter was revealed, doctors were not looking for a new cause of peptic ulcer, that territory had already been taken by the illusion of knowledge.
It was certainly a paradox and so everybody had ignored Magnus’s findings because they did not fit in with what people thought would be the norm. When I presented our data in October 1982 at a meeting in Perth, a local gastroenterologist said to me; “Barry you’ve got that wrong, people with duodenal ulcers don’t have gastritis. The stomach is usually normal.” From what I had seen of Warren’s biopsies, I could say “How do you know since nobody ever biopsies the stomach of duodenal ulcer patients?”
Interestingly, I saw many patients who had ulcer symptoms, but in whom no ulcer could be found. Many doctors believed that such patients had a psychosomatic illness. However, I soon collected many such “crazy people” in whom symptoms greatly improved during antibiotic treatment. I started to believe that it was not always necessary to have a visible ulcer in order to suffer from ulcer symptoms. Perhaps duodenal inflammation, a pre-ulcer condition, could cause pain.
I found the response to my presentations very illogical and rather irritating. One day, after I presented my histology data showing the healing of gastritis with bismuth, the senior hospital pathologist stated “Dr Marshall these changes seem very subtle.” Actually the changes were quite dramatic, and this was the first time anyone in the world had been able to heal gastritis! I bit my tongue to stop myself from saying “are you crazy?” Others suggested again that these commensal bacteria merely infected people who already had ulcers. But quite clearly I had presented data from patients with gastritis who did not have ulcers.

I realized then that the medical understanding of ulcer disease was akin to a religion. No amount of logical reasoning could budge what people knew in their hearts to be true. Ulcers were caused by stress, bad diet, smoking, alcohol and susceptible genes. A bacterial cause was preposterous.
I knew that most people continued to believe that ulcers were psychosomatic so it was important to ensure that patients were completely unaware of which treatment they received.
As part of the study I included a psychometric test called the Jung Scale, which approximately measures things such as sleep patterns, optimism, wellbeing etc. I wanted to see if the so-called ulcer personality had anything to do with the ulcer disease.
the Jung Scales showed that the patients’ mental status improved when I eradicated their Helicobacter. When patients were in remission from their ulcer, Helicobacter eradication correlated with significantly lower Jung scores. Thus it seemed likely that the “ulcer personality” merely reflected a diminished state of health related to chronic infection of the stomach.

Helicobacter - The Ease and Difficulty of a New Discovery
, Nobel Lecture by J. Robin Warren
Since the early days of medical bacteriology, over one hundred years ago, it was taught that bacteria do not grow in the stomach. When I was a student, this was taken as so obvious as to barely rate a mention. It was a “known fact,” like “everyone knows that the earth is flat.” Known facts can be dangerous; to quote Sherlock Holmes (Conan Doyle, The Boscombe Valley Mystery) “There is nothing more deceptive than an obvious fact.”
I was unable to convince the clinicians of the importance of the organisms. Generally, they did not believe they were there at all. ‘Everybody knows the stomach is sterile’.... Another common question was ‘If they are there, why has not anyone described them before?’ At that stage I did not know why I had not seen them, let alone no one else.

It has become apparent over the years that gastric bacteria have been described many times over the last 100 years. However, these descriptions were not generally known.... The apparent absence of any previous report was given to me as one of the main reasons why they could not be there at all.


fourthbreakfast said...

I thought of you when I read this week's Newsweek article on Lyme Disease:

Sometimes, it seems like we're still in the medieval times of medicine. I still laugh whenever I see the scene in Star Trek IV:

McCoy: What's wrong with you?

Elderly patient: I'm waiting for dialysis.

McCoy: Dialysis? What is this, the Dark Ages?

dancing dragon said...

Thanks, fouthbreakfast. :)

michele said...

thank you so much for posting this. I will be quoting this article in my own article about the discrimination that people with arachnoid cysts.