Abstract
There is one concept in medicine which is prominent, the symptom. The omnipresence of the symptom seems, however, not to be reflected by an equally prominent curiosity aimed at investigating this concept as a phenomenon. In classic, traditional or conventional medical diagnostics and treatment, the lack of distinction with respect to the symptom represents a minor problem. Faced with enigmatic conditions and their accompanying labels such as chronic fatigue syndrome, fibromyalgia, medically unexplained symptoms, and functional somatic syndromes, the contestation of the symptom and its origin is immediate and obvious and calls for further exploration. Based on a description of the diagnostic framework encompassing medically unexplained conditions and a brief introduction to how such symptoms are managed both within and outside of the medical clinic, we argue on one hand how unexplained conditions invite us to reconsider and re-think the concept we call a “symptom” and on the other hand how the concept “symptom” is no longer an adequate and necessary fulcrum and must be enriched by socio-cultural, phenomenological and existential dimensions. Consequently, our main aim is to expand both our interpretative horizon and the linguistic repertoire in the face of those appearances we label medically unexplained symptoms.
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Notes
Inspired by how the German philosopher Heidegger in his book “What is called thinking” dealt with an inscrutable theme such as thinking, we will try to “open up” that phenomenon we name symptoms. By launching the title “What is called symptom” we want this to serve as an invitation to reflection and re-thinking of this matter.
Besides IBS, other conditions subsumed under this label are food intolerance, CFS/ME, burnout, fibromyalgia (FM), somatoform disorder (SD), vertigo, hypochondria, whiplash and non-cardiac chest pain (NCCP).
The latest results from Fink’s group showed an overlap of symptoms and symptom patterns among a huge sample of patients and resulted in the development of the term BDD which refers to symptom experiences, is aetiology-neutral, leaves out behavioural dimensions and does not reinforce a mind–body dualism (Fink and Schrøder 2010).
A similar conclusion is reached by Olde Hartman et al. (2013), showing that although patients had time for extensive explanations, the GPs did not engage these in their own interpretation. This also relates to communication problems regarding patient expectations and incompatible explanatory models of disease (Salmon et al. 2005; Kirmayer et al. 2004).
Although the term “symptom” is a part of our everyday language in a diversity of spheres, we maintain that this wording primarily is identified with health/disease and the branch of medicine.
Cf. Irving, Zola (1983).
Such an interpretation evidently rests on insights from phenomenology. In this way, it resonates with explications from phenomenologists such as Robert Mugerauer (2009). In an effort to describe the complex and inscrutable arrival of the phenomenon with the one who is gifted (the receiver), i.e. “the way phenomena make unpredictable landings in our lives” (s. 73), he continues: “Phenomena arrive so discontinuously, so unexpectedly, and so much by surprise that our contribution amounts to no more than being open to what hits us. Often we can only await and make ourselves ready to receive what might come, as would a good sentry at night, a first step towards which is giving up our attempts to control, much less produce what appears” (ibid).
This is a phrase borrowed from the Norwegian philosopher Anders Lindseth.
The term pre-symptomatic is among other used by Kellerman (2008). Her refers to Engel And Schmale (1967), “who point to what they call a “giving-up/given-up” complex. This is a nonspecific pre-symptomatic state. It contains a cluster of tendencies and characteristics including: a lessening of control and a lessening of a sense of security, helplessness and hopelessness, less certainty of one’s perceptions of the environment and of past experience, and a clouding of differentiation between past and future (s. 7).
We repeat that this explication altogether do not hold a normative decree. It is an invitation. An invitation to reflect on the phenomenon named anxiety. Consequently, we agree with Prasad (Prasad 2009) which notes that: “The worry, if one takes Heidegger’s perspective, is not that health is an outcome to be optimized by cost-effective, evidence-based medicine, but that this might become the only way of thinking about health—that no alternative exists”. (p. 17).
More than a symptom carrying unambiguous misery, we are therefore confronted a Marcelian mystery. That is, we are confronted with what we are unable to treat as a problem—as an object for analytic investigation. In dealing with what is not a problem and which pervasively concerns our existence, a reflective exploration of such fundamental issues is not aimed at generating “solutions”. At best one can initiate a process whereby the present phenomenon is received as giving pause for thought. Consequently, pain will remain such a fundamental human condition independent of future medical breakthroughs as regards both diagnosis and treatments (Marcel 2001).
Symptoms may be symbols in a Peircean sense, signs in a Saussurian sense, dominant symbols following Good, expressions of distress following Kleinman, ‘texts’, narratives, metaphors, metonyms following others etc. Ethnography and anthropology must study the symptom as a symbol in some sense. This is notably a positive step ahead for studies of symptoms, but turning back to the entrapment by the notion, we argue that although symptoms are being elaborated, contextualized and differentiated as basic anthropology or social sciences do, the possibility of letting go of the word/notion and stepping back to have a look at the pre-symptomatic processes of bodily signs is lost.
This line of reasoning is however not restricted to a specific socio-cultural approach. The concept of “primary” sensations and embodied reactions also resonates with how a philosopher such as Kay Toombs (1993), inspired by Sartre, explicates the process whereby illness and disease is “constituted”. She heavily relies on Sartre’s analysis of pain and illness where he distinguishes between (1) pre-reflective sensory experience, (2) “suffered illness”, (3) “disease” and (4) the “disease state” (p. 230). We find that the first and second stage is of particular interest here. At the first stage (1) according to Toombs “one first becomes aware that all is not well in the felt experience of some alien body sensation” (ibid). At the second stage (2), “experience becomes one that must be given a meaning” (p. 233). Even at this second stage, she notes that “illness” at this point is not constituted as a particular illness—that comes at the next level of constitution”(ibid).
Importantly, any sensation is never merely a question of physiology but the meaning of sensations is culturally embedded, and mediated by social practices and symbolic systems of meaning (Howes 2003, 2005). Further, sensations are enacted and embodied through relational processes and thus important to whatever takes place concerning healing and care-seeking. As suggested by Hinton et al (2008), sensations are key sites of embodying metaphor, of memory making and of self-fashioning (2008).
This is an excerpt from his poem “Mnemosyne”.
She is here referring to the Americal philospher Peirce.
This point is also made by Queiroz and Merrell (2006), suggesting that “In sum, according to Peirce’s pragmatic model, semiosis, is a triadic, dynamic, context-dependent (situated), interpreter-dependent (dialogic), materially extended (embodied) dynamic process. It is a social-cognitive process, not merely a static, symbolic system. It emphasizes process rather than product, development rather than finality. Peirce’s emphasis rests not on content, essence, or substance, but, more properly, on dynamics inter-relations”.
A familiar line is presented by Damasio (2001) in his book “Descartes feiltakelse” (eng: Decartes’ error). He emphasizes that a scientific breakthrough whereby one discover how a distinct feeling is a product of an interacting between the brain-system and body organs, do not reduce or weaken this feelings status as a human phenomenon. The phenomenon named love is not devaluated due to an increased understanding of the complex biological process that contributes to it (p. 15).
In addition to this she emphasizes that “… melancholy is not reducible to contingent socio-cultural or psychological factors but rather is a human ontological condition par excellence….” (s. 192).
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Acknowledgments
The authors thank Torsten Risør and Erik Lundestad at the University of Tromsø and Randi Falnes Olsen at the department of Occupational and Environmental Medicine at the University Hospital of North Norway for valuable comments.
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Eriksen, T.E., Risør, M.B. What is called symptom?. Med Health Care and Philos 17, 89–102 (2014). https://doi.org/10.1007/s11019-013-9501-5
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DOI: https://doi.org/10.1007/s11019-013-9501-5