Showalter's Hystories/Joseph Dumit Comments(May 1997)

>From Joseph Dumit NIMH Research Fellow Dept. of Social Medicine Harvard Medical School 02 May 1997

Having read Showalter's book carefully, and having read the archived discussion of her book on this listserv (and H-SCI-MED-TECH), I offer the following observations regarding her analysis, argument, method, and conclusions. Please forgive the length and the quotes--based on the previous exchanges it appears necessary to make claims carefully and with support from her text.

At many time in _Hystories_ Showalter grounds her argument not in evidence, but in a moral imperative. To her credit she makes the imperative explicit: we (our society, ill-defined, but most likely "the West"), we must stop the current epidemics of hysteria, and we must prevent future epidemics. The only way to do this is to insist on the reality of hysteria in folks right now, regardless of the consequences to the individual sufferers. Let me illustrate this claim using the chapter on Chronic Fatigue Syndrome (CFS).

The fact that some doctors define or treat CFS as a form of hysteria is certainly enough to include CFS in a history of the "use of hysterical diagnosis." Showalter many times, however, asserts that it is imperative that hysteria be accorded the status of fact and truth. She thus steps out of a history of use of the diagnosis to the assertion of the diagnosis and the history of attempts to deny it or avoid it by certain unscrupulous, vulnerable, or deluded individuals. She in fact recants the thrust, if not the arguments of her previous work (on pages 10 and 59 she laments that some wing of feminism has gone too far with it, in ways she did not anticipate--"Some contemporary feminist theorists and therapists have inadvertently helped to spread new hysterical disorders." (10) ).

Showalter does argue that hysteria is a real, non-biological illness. She does this while not acknowledging the tremendous conflict within the medical profession (her putative sources) over the scope and variability of the diagnosis. Specifically, she writes as if being able to locate hysteria as existing in some patients is enough evidence to find real hysteria wherever it has been diagnosed.

First, she opens the chapter on CFS with a newspaper account of a woman who claims to have been cured of CFS by a faith healer. Showalter makes it clear that this newspaper account demonstrates that CFS is really hysteria since it can be healed by a faith healer.

(Rhetorically we might note that she assumes 1. The veracity of the newspaper account and the woman's claim within it. 2. That the woman did in fact have CFS and that it was cured. 3. That we all know that faith healers can only cure hysterical (or imaginary, see chap.2) symptoms.)

We can contrast this with whether a newspaper account of one case of a faith healer curing AIDS would ever be treated by Showalter similarly. In other words, Showalter expresses extreme skepticism regarding CFS symptoms in general, but amazing credulity regarding a newspaper account of a faith healing. After devoting the entire opening paragraph of the chapter on CFS to a young English woman "miraculously cured by a faith healer," Showalter continues: "But there was no faith healer around to help an entire family with chronic fatigue in Dundee, Scotland." (115).

Later on she turns to a dismissal of any evidence that CFS is possibly biological. Instead, one side is asserted as fact and no historicizing of the research is presented. It should also be noted that Showalter relies solely on a selective collection of histories of CFS, media accounts, and books written in support of CFS. Her main argument is that two medical studies claim there has been no definitive biological marker located for CFS (one cited on the basis of a _USA Today_ article). The lack of definitive biological causation is certainly true in the sense that there is no consensus within the medical community. However, there is tremendous disagreement within medicine over this issue that is not acknowledged except to be dismissed.

In addition to the histories cited earlier by George Gale, interested persons should also check out Simon Wessely's (1994) chapter in Stephen E. Straus, Ed. _Chronic Fatigue Syndrome_Marcel Dekker: . And also E. Acheson (1959) in _Am J Med_55:102-22; and Jenkins (1991) in Jenkins, R, Mowbray J _Post-Viral Fatigue Syndrome_Wiley. The latter two are arguments for the reasonable consideration of CFS as viral-caused. The arguments are cited as persuasive by otherwise unsympathetic authors such as Wessely. The Straus book, however, is part of a series entitles _Infectious Disease and Therapy_. Another book, _Chronic Fatigue and Related Immune Deficiency Syndromes_Goodnick & Klimas, Eds. (1993) is part of the _Progress in Psychiatry_ series by the American Psychiatric Association, and carefully offers that there is a history of fatigue-related diseases that is _separate_ from the history of neurasthenia--chronic fatigue syndrome seems related to both. Showalter does cite Wessely's work many times, but does not attend to his careful reading of the histories of attempts to interpret, diagnose and treat CFS.

Showalter appears to argue that since we _know_ that CFS is a hysterical epidemic, then we know that those physicians and researchers who are looking for and publishing studies investigating possible biological aspects of CFS are in fact "physician-enthusiasts" (Hysterical epidemics require at least three ingredients: physician-enthusiasts and theorists; unhappy, vulnerable patients; and supportive cultural environments." (17) 0. At the risk of being redundant, she provides no evaluation of the conflicting sides or cumulative studies. Very simply, Showalter seems to be claiming that there is no need at all to investigate the possibility that CFS might have a biological basis in at least some people. To investigate it would be given more credence and therefore to fan the flames of the epidemic of hysteria:

"Research into the causes of CFS is a way of life for many people as well. Hundreds of costly studies [that] have failed to find convincing evidence of the bacteria, chemicals, and viruses hypothesized as the causes of CFS...The failure to discover a cause from CFS after millions of dollars of experimental funding doesn't rule out the possibility that there may yet be a cause beyond current medical knowledge. No doubt as you read this book, headlines are proclaiming another breakthrough..." (125).

This is not the place to review the evidence regarding CFS, there are books and articles and arguments for and against the research that has been done (see above). Consider instead one of the top neuropsychiatric researchers in the U.S., Nancy Andreasen's recent review of state-of-the-art mental illness research in _Science_.

"There are at present no known biological diagnostic markers for many mental illnesses except dementias such as Alzheimer's disease. The to-be-discovered lesions that define the remainder of mental illnesses are likely to be occurring at complex or small-scale levels that are difficult to visualize and measure...In the absence of a pathological marker, the current definition of mental illnesses are syndromal and are based on a convergence of signs, symptoms, outcome, and patterns of familial aggregation." (Andreasen 1997: 1586-7).

Would Showalter apply her scathing critique of wasted money and over-optimistic science to schizophrenia and depression and conclude that because they have failed to discover "convincing evidence ...of [their] causes" that research into them should be stopped? Or would she temper it? Curiously, she avoids the entire field of mental illness except somatization and contrasts hysteria with AIDS (a real disease with a real virus). I am strongly suggesting here that the difference between CFS and schizophrenia or depression for Showalter is primarily her apriori (or credulous) _assumption_ that CFS _is_ (and is always) hysteria.

The most troubling section on CFS for me was the dismissal of patient suffering. Showalter nicely summarizes some of the Kleinman and Mechanic's stances on CFS from a Ciba Foundation symposium on CFS held in 1992. Kleinman advocates for _physicians_ and not psychiatrists seeing CFS patients because of the dissonance and delegitimatization that accompanies the experience of psychiatrists not emphasizing the somatic. Mechanic follows up: "Much as my inclination is to believe that CFS is influenced by psychological needs, I am not convinced that there isn't an important vital trigger or viral perpetuating factor. I see no reason why the public should give up that belief, when you don't have anything particularly good to offer in return." (Mechanic 1993 in Showalter 1997:131). Showalter however, refuses this approach to patients with an apocalyptic worry about the future:

"But these kindly, tolerant, and temporizing views do not address the ways that psychogenic epidemics escalate. Doctors may protect the self-esteem of their patients in the short run by prescribing placebos like vitamins and avoiding public statement about the history of effort syndromes. But in the long run, such an acquiescence only creates more hystories." (131).

Note that Showalter dodges completely the lack of proof that CFS isn't related to a virus or has an organic component. She reduces the therapeutic alternative offered by Kleinman and Mechanic to lying to the patient, offering placebos, and helping their self-esteem. (Though there are many hints that Showalter sees CFS and the other hysterical epidemics simply as problems of self-esteem.) She also refuses to see the lack of any help or respect accorded to CFS (she sees it as a completely enabled condition). Finally, she foregrounds her real worry, that this might help people now but the real problem (for her, not the current sufferers) is that there will be more and other kinds of hysterical epidemics. Apparently she feels that if enough people just took these epidemics seriously as hysterical outbreaks, we could break the historical pattern of hysterias.

She concludes by suggesting that Gulf War Syndrome is the next chapter in the history of epidemic hysterias. Her next chapter is on GWS, and I won't take up any more space here, except to note that she consistently chooses to use as examples of GWS the most extreme cases reported by the media (she cites, for example, an _Esquire_ report that two vets claim to be shrinking). She clearly intends these to be proof that there is no biological cause for GWS. "Gulf War syndrome is shaping up to be a tragic standoff of men and women suffering from the all-too-real aftereffects of war, doctors unable to combat the force of rumor and panic, and a government that feels the need to be supportive of veterans." (141). She is patently dismissive of anything but the full recognition of the fact that GWS is neurosis, or PTSD, and that as such it deserves respect as a form of suffering. She claims that every cause, chemical, vaccine, bacteria, smoke brought up by veterans has been or will be found lacking by the government. "Meanwhile, thousands of men and women who could be helped by psychotherapy are instead encouraged to pursue endless tests and medical exams" (141), and concludes that with conspiracy theories, "...Gulf War Syndrome becomes an epidemic of suspicion, a plague of paranoia that threatens a greater malaise than even Vietnam." (143).

What should CFS or GWS sufferers do with this book? What about those of us learning how to relate to those who are suffering? Showalter clearly and repeatedly suggests that they are in need of psychotherapy and need to be disabused of the notion that there is any possible biological cause of their symptoms. She emphasizes that admitting the _possibility_ of biological cause is part of what feeds these kinds of epidemics. In summary, in my opinion, she takes a very adamant stand on the real status of the syndromes based on slim and often specious evidence.

I will stop here but encourage response from those who have read the book and who have other readings. If there is interest I can post a more developed bibliography and analysis of either CFS or GWS, and of the rest of Showalter's book.

Joseph Dumit
NIMH Research Fellow
Dept. of Social Medicine
Harvard Medical School

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