Abstract
Psychogenesis of physical signs and symptoms is a concept which doctors find hard to keep in mind, even though they are confronted with its expression numerous times a day. Why is this so? Dr Yolande Lucire explored this in breadth and depth in her PhD thesis, now condensed and edited for more popular consumption in this book. Repetitive strain injury (RSI), an Australian neologism and indeed an Australian creation, Dr Lucire argues, is the paradigm that she uses, but a similar book could have been written about any of the epidemics of somatization from the past, including telegraphers' cramp, writers' cramp, sick building syndrome, multiple chemical sensitivity and, some would argue, Gulf War syndrome. There is a vast literature about this, including Paul Lerners' recent splendid account of ‘war neurosis’ in the German Army of the World War I, entitled Hysterical men (Cornell University Press, 2003). It would appear that those doctors who facilitate and perpetuate such epidemics do not learn the lessons of the past. Dr Lucire takes us through the pertinent sociological, philosophical and clinical concepts that inform our current views about psychogenesis. Importantly, she reviews the concepts of sickness, illness and illness behaviour. Seminally, she discusses Parsons' concept of the sick role and iatrogenic contributions to this.
From this background we are provided with a definitive account of the outbreak of the epidemic of RSI in Australia, to which place astoundingly but not surprisingly it was more or less confined. This is gripping reading. More disturbing is the account of the way in which doctors, lawyers, judges, trade unions and the National Health and Medical Research Council contributed, knowingly or unknowingly, to the epidemic. Most disturbing of all is the account of the personal attacks on Dr Lucire, some of which I witnessed myself. She points out how she was misunderstood as accusing patients of malingering and not acknowledging their suffering. There follows 20 case vignettes from a larger series on which her thesis was based. These vividly portray the range of issues discussed earlier, including the sufferers' plight and the wider context of suffering in which the specific presentation occurred.
Distinguishing between malingering and hysteria is a challenge. Clinicians have come to regard these as lying on a spectrum; they focus on the symptom rather than adopting a moral stance. The opposite is true in the medico-legal arena. Dr Lucire's use of the category ‘malingering’ in her analysis of the cases could be construed as redolent of the latter. This highlights the dilemma for a professional who is both a clinician and an assessor. However, a careful reading of the book will convince the reader that Dr Lucire sees these patients (who are almost all women) as social sufferers who somatized their distress and then became caught up in a medical and legal system which determined their subsequent manner of presentation.
Reducing a PhD thesis to a comprehensible text for a mixed audience is a major challenge. Dr Lucire acknowledges the help received from her editor in this task. Some readers may be frustrated by resultant variation in style and the limited referencing. However, they should be able to access the thesis at the University of New South Wales; I hope that they will, just as I hope that all those who have to deal with somatization and its consequences will read this book. As Dr Lucire so vividly portrays, this includes patients, families, health professional, the law and society at large, often in ways of which the individual is unaware.