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The Only Certainty Is Uncertainty

Admitting to uncertainty is truer and safer than jumping to false certainty. That's why I see no proper role in the DSM for the made-up and unresearched diagnosis Somatic Symptom Disorder. To worry about having a physical symptom is not a psychiatric disorder -- it is part of life.
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The clearest lesson we can learn from scientific progress is how much we don't know and perhaps cannot ever know. During the Victorian era, scientists were confident they could predict the behavior of everything from giant galaxies to the smallest atoms from some the simple mathematical rules worked out 200 years before by Isaac Newton.

But that confidence dissolved in the 20th century in the face of the spooky weirdness and unavoidable uncertainty of quantum physics. And we face the disorienting reality that most of the matter and energy in the universe is, and may remain, 'dark' to us because our senses were not evolved to detect them. What we don't know is a lot.

Uncertainty is an even more pervasive problem in medicine. But usually it is drowned out by medical drum beating -- each scientific advance is trumpeted as a thrilling breakthrough, providing the always illusory hope that we are on the very brink of solving and controlling illness. But the promise is never delivered and the more we know, the more we discover how much we don't know.

When I began medical school 50 years ago, nearly everyone expected that man made antibiotics would soon decisively win the battle against the lowly disease causing bacteria that had caused so much suffering and death throughout human history. Lately, however, the clever bacteria seem to be consistently gaining the upper hand in the chemical arms race with the drug companies. Similarly, our country declared war on cancer in 1971, but we are still losing most of the battles. And the decoding of the human genome was an incredible technical triumph, but so far has done little to explain or help cure disease.

The workings of the human body are far too complex to be easily understood or readily modified. If ever there were a need for humility, it would be among medical professionals. But my experience suggests that humility is the one trait many doctors most sorely lack and need to learn.

Laurie Endicott Thomas, a medical editor, science writer, and author of Not Trivial shows how this lack of medical humility can have serious human consequences.

Ms. Thomas writes:

"The three most important steps in managing any illness are diagnosis, diagnosis, and diagnosis."

"But what to do with the many patients who present with physical symptoms that defy quick and accurate diagnosis. Doctors who are wise admit they don't know what's wrong -- while those who are less humble often often assume that the cause of the puzzling symptoms must be 'in the patient's head.'"

"Resorting to the false certainty of 'it is all in your head' is dangerous. Once doctors have dismissed an illness as psychosomatic, they stop looking for the correct diagnosis and the patient may never get the right treatment."

"'It's all in your head' also adds insult to injury. Patients always interpret the phrase as a dismissive put-down."

"Finally, 'It's all in your head' is illogical. The medical profession traces its ancestry to the wonderful ancient Greek physician Hippocrates. But the great Greek philosopher Socrates also has an important lesson for doctors -- one can learn only after accepting that one does not know. To relieve patient suffering and protect patients from harm, doctors must first recognize the limits of their knowledge and skill -- something they often fail to do."

"In every other human endeavor, things that are 'unexplained' are distinct from things 'unexplainable.' But in medical practice, these two are often assumed to be one and the same. Patients with 'medically unexplained symptoms' are assumed to be patients with 'medically unexplainable symptoms,' which are then dismissed as psychiatric. Cases of medical uncertainty become cases of psychiatric certainty, not through investigation or evidence, but by default, simply as a function of the way the words are used."

"The conceit of certainty might be remotely defensible if doctors had a really good track record for accuracy in diagnosis. However, diagnostic error rates are high -- roughly 40 percent compared to autopsy results."

"In the absence of evidence for specific psychiatric disorders, patients suffering from medical symptoms that are hard to explain must remain medical patients."

I agree with Ms. Thomas. Uncertainty is always uncomfortable but is nothing to be ashamed of. Admitting to uncertainty is truer and safer than jumping to false certainty.

Two consequences are obvious. If we can't figure out the cause of physical symptoms after thorough evaluation, we should admit as much to the patient and figure out the best way of living with the uncertainty and coping with the symptoms. Providing a phoney name for them adds nothing of value and may complicate things further.

That's why I see no proper role in the DSM for the made-up and unresearched diagnosis Somatic Symptom Disorder. To worry about having a physical symptom is not a psychiatric disorder -- it is part of life.

And we need to embrace uncertainty also in psychiatry. Many presentations defy specific diagnosis are are best labelled within the many Not Otherwise Specified categories sprinkled throughout the DSM. These are to be celebrated and used freely because they often most accurately reflect the state of uncertainty about the diagnosis and and avoid a reckless rush to premature judgment.

A psychiatric diagnosis is a potentially life-changing event: it can do great good when accurate, great harm when not.

It is always better for physicians to accept uncertainty and make no diagnosis, or a non-specific one, than to give an irrelevant or false one.

Editor's note: The first four paragraphs in the blockquote above are from Laurie Thomas and the second four, that did not receive proper attribution, are from Diane O'Leary.

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