Margaret Williams writes:


This excellent paper is 38 pages long; it can be found in full at

http://art-bin.com/art/dalen_en.html and is very highly recommended.


As Associate Professor of Psychiatry in Sweden and a long-time debater of issues concerning the independence and reliability of medical research, Per Dalen discusses some of the reasons which may underpin the increasing dominance of certain psychiatrists (together with their methods and means of maintaining the status quo in “modern” medicine) with particular regard to “medically unexplained” disorders such as ME/ CFS, multiple chemical sensitivity, amalgam illness, fibromyalgia and several other illnesses that established medicine has so far failed to explain scientifically.


[Readers will doubtless be aware of the published views on such disorders of Simon Wessely, Professor of Epidemiological Psychiatry at Guy’s, King’s and St Thomas’ School of Medicine and The Institute of Psychiatry, London, where he also runs both the Chronic Fatigue Syndrome and the Gulf War Illness Research Units].


The following extracts are direct quotations from Per Dalen’s paper.



“There are many indications that the popularity of modern medicine is declining.  Doctors are facing various problems that seem to be growing, such as sceptical and inquisitive patients who tend to seek information and help outside conventional medicine. The professional debate shows rather plainly that many doctors…tend to react with frustration when their professional authority is not being fully respected”. 


“Traditional values such as “science” and “evidence-based medicine” are being defended. Alternative and complementary methods are beyond the pale”.


“On the other hand, there is a theme that not only survives inside the medical culture in spite of an almost total lack of scientific support, but actually thrives there due to the support given by leading circles.  This is the use of psychological theories as a means of reclassifying bodily symptoms as mental problems in cases where conventional medicine is at a loss for an explanation, particularly patients with so-called new diagnoses.  Patients often feel insulted by this act of reclassification, which is often accompanied by signs of impatience on the part of the doctor”.


“Since I am a psychiatrist, I have for a long time been intrigued by the extraordinary use of psychiatric causal explanations for illnesses that not only go with predominantly somatic symptoms, but also lack any basic similarity to known mental disorders”.


“Are patients being helped by this peculiar way of interpreting their illnesses?  No…there are pronounced complaints of some considerable duration”.


“On the other hand there is no denying that certain interested parties are being helped…

I cannot exclude the possibility that psychiatry is being abused in order to sweep certain sensitive problems under the carpet”.


“We have here a possible ethical problem.  If physicians were in the habit of thinking independently and…were willing to show civil disobedience, problems like these would never have to arise”.


“Earlier examples of abuse of psychiatry in Nazi Germany and the Soviet Union unfortunately show that physicians are no more upright than others in the face of signals from people they regard as their superiors.  The herd instinct may even be stronger…than among people in general”.


“I should like to discuss different aspects of medical attitudes to questions that somehow involve all those people who have been unfortunate enough to fall victim to illnesses that are officially counted as probably non-existent”.


“Medical science has a really weak side that is not being discussed very often.  Research into causes is making no progress in important areas…there is no real research into causes…Going straight for the cause is regarded (as something that) real scientists are not supposed to do.  From the point of view of your career it would be very unwise to mention that you hope to be able to search for unknown causes of disease.  Everybody “knows” that this is far too difficult”.


“For example…autoimmunity does not arise from nothing, but…we know very little about its causes.  Prevention and treatment are poorly developed (but) many scientists are dreaming of drugs that are tailored for a specific purpose such as blocking the autoimmune mechanism…There is a considerable risk that serious adverse effects will occur (with) chemical interventions.  We should rather look for…an external disturbing factor (including nutritional deficiencies) which we might eliminate.  Our genes serve us exceedingly well as long as the environment keeps within reasonable limits”.


“The important misunderstanding that survives even today is that a “hereditary background” to a disease means an involvement of genes that are abnormal and should be “repaired” but this is rarely the case….most of the facts point towards the environment as decisive in these cases.  If the incidence of a disease is increasing rapidly in the population, this increase cannot be due to a sudden change in the frequency of certain genes.  Blaming heredity can often become an evasive argument, particularly so in medical science, with its lamentably poor record of research into causes, particularly where environmental factors are concerned…The less we talk about the environment, the better for the business prospects of the geneticists…Genetics in reality is still only of use in connection with certain rare diseases”.


Epidemiology is another specialty that is reputed to carry the keys to causes of disease. Originally this was the science of the occurrence of (infective) diseases.  Now it has developed into a versatile discipline which uses statistics as its basis (and) has almost acquired the status of a basic science in medicine”.


“In many situations…epidemiology is often rendered useless because of a sharp decline in the sensitivity of the methods…  This is further aggravated if there are also problems of classification or definition.  What is found are of course statistical associations, not causal links…there are almost always objections to the hypothesis that this might represent a real causal link”.


Fact box: Epidemiology.  Today, epidemiology deals with all kinds of diseases and their distribution and causes.  The idea is to find patterns in how illnesses appear.  The working tool within epidemiology is foremost statistics.  Epidemiology is not well suited for studying more rare effects of mass exposure, since the methods used are not sensitive enough to indicate a connection that is actually there and which is of importance.  Still, one often encounters so called “negative studies” which readily are interpreted as evidence of how harmless some suspected factor is”.


“Behind every product on the list of suspects there is at least one worried branch of industry.  The tobacco industry learned early on how to handle epidemiology by sowing doubt about the meaning of the findings, which is a very useful method of “damage control”….When modern PR consultants are trying to clear an industrial product from suspicion they take it for granted that only epidemiology can produce final proof in such matters.  And the medical establishment will nod approvingly without giving much thought to the problem…..Many medical problems have been handed over to epidemiology without ever being solved”.


“When science, unassisted, is unable to fully answer important controversial questions, other parties will gradually take control of the situation.  First of all, of course, any industries involved, then public authorities and political assemblies…in order to take important decisions even before the scientists have reached consensus, which may take a very long time”.


“Epidemiology is thus open to criticism because its methods generate many…associations that will tend to linger indefinitely without science being able to decide the matter one way or the other.  Epidemiologists are first of all statisticians (and) their opinions on causal connections must often be taken with a pinch of salt, particularly when it is a question of denying a connection on purely statistical or theoretical grounds. What makes an individual human being ill cannot be determined by statistics”.


“If sponsors from industry could have their way, epidemiologists would produce even more so-called “negative studies”, which do not show an effect of the factor studied….It used to be common knowledge among scientists that such studies don’t prove anything at all, and journal editors were not particularly keen on publishing them.  This has changed…There are many possible reasons why an epidemiological study yields a “negative” result…It is expensive to perform epidemiological studies that are of high quality and large enough, and therefore a proportion of studies will turn out to be negative even though there is a causal connection; (moreover) it is quite possible to plan for a negative study.  Epidemiology is risking its reputation by having too much to do with research that cannot prove anything”.


“Remarkably often, it was chance that showed researchers a way that led to important progress”.


“At present there is an obvious risk that we may simply be looking in the wrong places and fail to see novel and unexplored possibilities.  All large-scale enterprises have difficulties with adaptation at short notice.  No new knowledge can be found incorporated in long-term planning”.


“ ‘Holistic medicine’ can be seen as a warning against one-sidedness and ‘reductionism’.  It is never a good idea to over-simplify, acquiring only parts of available knowledge and then applying this in a cut-and-dried way”.


“Lack of knowledge is a considerable handicap, particularly in the treatment of chronic diseases.  Many patients are aware of this and turn to alternative practitioners.  How does medicine handle this problem?  Officially, established medicine is the place where only methods of proven value are being used”.


“If we are not allowed to have a ‘free sector’, certain valuable (alternative) drugs (which) cannot be patented and are therefore not interesting to the pharmaceutical giants will disappear”.


“Alternative methods rarely carry the official stamp of approval, but in spite of this more and more people are turning to this sector for help.  This is of course a matter of concern to established medicine which has no ready explanation why its share of the market is diminishing.  The idea that alternative methods actually yield good results is mostly avoided.  Instead recourse is to a seemingly obvious explanation, namely that all the positive effects claimed to have resulted from alternative treatments are simply placebo effects”.


“Here, certain rules that have become established since the middle of the 20th century are being exploited.  It is regarded as self-evident that a method of treatment should be demonstrably better than placebo in order to become officially approved.  Clinical judgment or other informal ways of sifting evidence are not accepted”.


“According to a statement that has been cited innumerable times since the 1950s, a placebo makes the patient feel better in about 35% of cases  (ref: The powerful placebo. HK Beecher.  JAMA 1955:159:1602-6).  It would take 40 years before a German physician (Gunver Sophia Kienle) exposed this still very often quoted paper as full of careless mistakes and misinterpretations.  The 35% improvement rate is plainly a gross exaggeration (but) the otherwise so meticulously critical medical community has been living for decades with a picture of reality that has not been checked.  Why?  Could the reason be that this story was too useful in its original form?”


“Today some further facts have been added to Kienle’s revealing analysis and the placebo effect has shrunk into something that can only just be shown to exist.  It would be remarkable if no great differences were to be found between different diseases and situations regarding the immediate and long-term influence of diffuse psychological factors.  Lumping them all together, as has been done for nearly half a century, would simply be intellectually dishonest now…  In May 2001 (Danish researchers from Copenhagen found that) when improvement was measured as a simple ‘yes or no’ there was no tendency for placebo to be more effective than no treatment ”. (ref: Is the placebo powerless?  An analysis of clinical trials comparing placebo with no treatment  Hrobjartsson A, Gotzsche PC. NEJM 2001:344:1594-1602)


Accordingly, placebo is not the strong factor it has long been believed to be (and) quite a lot of rethinking will be required”.


“Placebo theorizing has been built on fairly uncritical arguments like the following: ‘since it is possible that psychological factors can restore health  (ie. the placebo effect), we have to assume that this is a fairly common problem’. (This common problem has) a mirror image (which is) very important: since it is possible to develop symptoms of disease via psychological mechanisms, then this phenomenon may underlie all those manifestations of disease that medical science cannot at present explain”.


“The starting point was Briquet’s syndrome, or Briquet’s hysteria, a chronic disorder with a miscellany of somatic symptoms which is much more common in women….The following quote from a long article on sociopathy tells us something about how the disease was regarded:


           ‘a model of…sociopathy (was) based on the premise that sexual opportunism and manipulation are the key features driving the sociopath and the evolution of sociopathy. Harpending and Sobus (1987) posited a similar basis for the evolution and behavioural manifestations of Briquet’s Hysteria in women, suggesting that this syndrome of…attention-getting is the female analogue of male sociopathy”.


“Later this condition was given a new name, Somatization Disorder, and was subsequently inflated and changed into something that is now claimed to very common”.


“Today it is common to talk about somatization as if this were something that is really understood.  It is supposed to be a condition with psychological causes, where looking for somatic explanations is useless (and) should be avoided, because it may make the patient even more preoccupied with bodily complaints”.


“…the label “somatization” (now) covers so very much more (than simply Briquet’s syndrome) and is only remotely similar to the original; (moreover), that Briquet’s syndrome should have psychological causes is not at all self-evident, and today few psychiatrists are likely to maintain such an hypothesis”.


“(Somatization) is hardly a natural category, but was pieced together and adapted by moving boundaries and stretching earlier assumptions….The result is a rather pretentious thing”.


“Therefore it must be noted that there is no proof that it is justified to apply the label of somatization to such conditions as electrosensitivity, amalgam illness, chronic fatigue syndrome, multiple chemical sensitivity and several more illnesses that established medicine has so far failed to explain scientifically”.


The boundaries of somatization largely coincide with the current limits of received medical knowledge”.


“Somatization and placebo effect are in fact two sides of the same coin.  Since the belief that placebo is a powerful factor has been found to lack (factual) support, growing doubts can be expected (about) somatization (being) such a (reverse) mechanism.  If more and more people start asking for scientific evidence, the inflated bladder will soon (be) punctured”


“For quite some time, peptic ulcer, arterial hypertension, asthma, ulcercous (sic) colitis, migraine, painful menstruation and certain skin diseases were regarded as …psychosomatic, (which) nowadays are treated with predominantly somatic methods”.


“It should be noted that somatization is a psychiatric diagnosis, which physicians in somatic disciplines are encouraged to apply to patients with predominantly somatic complaints”.


Somatization is a label you use when no conventional diagnosis seems to fit”.


“By stating as …fact that the causes are psychological in these cases…you will be spared the trouble of considering other possible explanations of those obviously somatic symptoms”.


“It is hard to follow the steps of the highly esteemed diagnostic culture of medicine within a sector that is said to be large and important from the point of view of general practitioners…of course the physician has tried hard, but failed to fit the patient into a conventional category.  According to a logic that is not exactly crystal clear, this leads to the conclusion that there is no somatic illness”.


“Diseases that are not found in today’s book of somatic diagnoses will have to be mental.  At once the physician knows what caused all the symptoms”.


“Why should somatization be a scientifically satisfying causal explanation (for) a great variety of symptoms?   This is a very good question which is heard all too rarely.  Only a few decades ago, borreliosis  (Lyme disease) was a “non-existent” disease, and many patients were then regarded as psychosomatic cases, just because of medical ignorance.  It didn’t matter that they often had acutely inflamed joints, as well as other indisputably somatic symptoms”.


“The question is what is medicine doing in this back yard where lack of firm knowledge is converted into speculative assertions without any critical voices being heard”.


“Many doctors would never let themselves be caught with woolly ideas about the possible causes of cancer, multiple sclerosis or cardiovascular diseases.  But just mention the word somatization and they will feel free to engage in uncritical speculation”.


Don’t hesitate to ask questions about the scientific evidence behind this talk about somatization.  Be persistent, because a diagnosis of somatization is definitely not an innocuous label.  It will close various doors and lead (to) treatments that usually get you nowhere.  But be prepared:  ‘resistance’ against the diagnosis will be taken as confirmation that it is correct”.


“As a psychiatrist, I have to say that it is distressing how unconcernedly certain colleagues are abusing psychiatry, allowing interests other than those of the patients to take precedence”.


“There is not even any ‘scientific necessity’ behind the whole thing…If the somatic doctors feel that they cannot find any explanation or accepted diagnosis in a given case, this certainly does not mean that the cause must necessarily be psychological”.


“Only a minority of psychiatrists are actively involved”.


“Some people are aware that something must be wrong with the ideas behind so-called somatization.  I am thinking of patients who have been subjected to a diagnosis of somatization, (many of whom) have been looking desperately for help (for) years (because of) an obscure disease that has deprived them of their working capacity and made life miserable”.


“Mats Hanson gives an excellent description of health problems that may occur if our bodies are being exposed to mercury, an extremely toxic metal for which there is no natural biological need”.  (ref: A hundred and fifty years of misuse of mercury and dental amalgam: The Art Bin: 2002).  Dental trade organisations have been doing their best to reinforce (the) view (that amalgam is harmless).  It would be possible to phase out amalgam, but strategists within the trade feat the avalanche of litigation that would be set in motion if the side effects of amalgam were to be recognised….American dentists are being supervised by state Dental Boards manned with dentists who are reliable adherents of the amalgam policy of the American Dental Association.  It is absurd to claim that an implanted material is so extremely harmless to the human body….the properties of mercury are definitely such that a whole array of adverse effects should be expected from chronic exposure….No reliable system for spotting and reporting side effects of amalgam has ever existed….amalgam is constantly leaking mercury…the fact that a drug is allowed to remain on the market does not mean that it is free from side effects.  The official answer to the question whether side effects occur is a persistent no, no.  There is in fact no other choice if you are trying to build up a defence against litigation.  Not surprisingly, findings from ‘negative’ epidemiological studies have been included as important evidence”.


“After spending my professional life in the medical culture I know perfectly well that much prestige is attached to the idea that our scientific standards are high”.


“I believe it is important for the health conscious public to became aware of these points that are directly relevant to the efforts of individual people to improve and maintain their own health”.


“Today many of us feel that it is necessary to gain knowledge that goes far beyond what is being offered in established medicine.  I have tried to discuss certain areas where the official view apparently lacks a firm contact with reality.  It is useful for you to make plain that you will not be impressed by specious arguments.  In this way we can help the physician to wake up and start doing something about the situation”.