Abstract
The central thesis of this book is simply stated. Many afflictions of modern-day developed countries, including not only ‘whiplash’ but also repetitive strain injury, chronic fatigue syndrome, ‘hypoglycemia’ and environmental sensitivity syndrome are all largely artificial entities, constructed mainly by health practitioners (with some help from the fabrications of their patients), mainly to line their pockets when ‘real’ illnesses are in short supply. Such diseases, according to Dr Malleson, make a substantial contribution to the burgeoning costs of health care, which continue to increase even though we are all healthier now than we have ever been. In the case of whiplash, everyone it would appear, is happy to board the bandwagon: orthopaedic surgeons; neurosurgeons; dentists (whiplash-induced temporo-mandibular joint dysfunction); ear nose and throat surgeons (whiplashinduced dizziness and tinnitus); neuropsychologists (whiplash-induced post-concussion syndrome); rheumatologists (whiplash-induced fibromyalgia); and ophthalmologists (whiplash-induced weakness of convergence and accommodation).
His fellow psychiatrists do not escape Dr Malleson's wrath as he points out that the symptoms of posttraumatic stress disorder following motor vehicle accidents have become more florid and more common with the growing availability of compensation.
At first sight, this is indeed an alarming vision: a sort of health-care piggery where both the carers and the cared-for are firmly preoccupied with keeping their snouts in the trough. However, the vision may well be an illusion. Firstly, there is no doubt that it is biased, perhaps heavily so. Dr Malleson freely (and courageously) admits that he has spent most of his professional life as a ‘defence’ expert (i.e. providing reports for the court on behalf of insurance companies and government agencies). It is the job of defence experts to see the world through the darkest of dark-coloured glasses and to suspect malingerers behind every affidavit. Certainly malingerers exist, as do self-serving health practitioners, but Dr Malleson's dire prophesies that they are about to bankrupt the healthcare system are not convincing. Despite his insightful discussions of evidence-based medicine, he is too ready to find fault with studies whose conclusions are not favourable to his cause and to accept those which agree with him. In some cases, support for his views is drawn from court judgements, which is a nice piece of irony considering his own (often appropriate) condemnation of the law as being too willing to accept ‘junk science’.
A second criticism of this book is that its thesis is too crude to provide a meaningful explanation of the phenomena it is describing and certainly too unsophisticated to guide the development of policy in this complex area. Certainly, health practitioners and their patients are greedy, and the financial incentives for the promotion of new ‘illnesses’ and their ‘cures’ cannot be underestimated. However, practitioners and patients are also anxious, insecure, unhappy, bewildered and frightened; they need friendship, reassurance, acceptance, concern, empathy, compassion and some sort of explanation (however unscientific) for their distress. Thus, for example, Dr Malleson seems to equate the distress of those who have ‘repressed memories’ of child sexual abuse with the bizarre statements of those claiming they have been abducted by aliens. Such comparisons inevitably will be regarded as being both unnecessarily distressing and quite unhelpful.
Finally, (and perhaps pedantically), one has to note that the writing style, although engaging and amusing, can ramble. Some figures (particularly those on p. 370) are confusing and inadequately labelled and explained.
Is there a point to reading this book? I think that there is for psychiatrists. We are constantly in danger of becoming complacent and we need to be reminded that our patients don't always tell us the truth, that our diagnoses often don't make sense scientifically, that we still don't know whether, how and why our treatments work, that we remain ignorant of how our interventions affect the wider community and that often we have no idea of what is going on in the minds of either our patients or our health care colleagues. We need to be particularly aware that we can create illnesses as well as cure them and, even when a psychiatric disorder is present, the cure is sometimes worse than the disease. There are still too few books which encourage us to think about what we do. That is a pity because in 20 years' time we may well have to cope with the ridicule of our successors who will regard our current diseases and remedies with the same scorn that we now assign to Charcot's hysterical fits or Mesmer's animal magnetism.