Hacker News Reader

>On what basis do you dismiss the physical sensations felt by these people as nothing but anxiety resulting from surgery?

The parent comment wasn't dismissing it. Quite the contrary. You, however, do seem to be dismissing it, by saying "nothing but anxiety". Anxiety is very real.

>Would you similarly dismiss phantom pain and prescribe anti-depressants and CBT?

Pain can quite often be caused/exacerbated by psychological factors. Perhaps you should google "central sensitization". The parts of the brain that registers pain (the insular cortex and ACC) are also responsible for attaching emotional feelings to pain. In some cases (e.g. fibromyalgia) the pain persists in the absence of any physical pain signal.

If someone is experiencing a physical symptom and you tell them it's not actually physical, that is dismissing it. If someone has whiplash from a car crash and you tell them the pain is just a result of their anxiety about the crash, that is dismissing their physical pain. Because the pain actually has a cause independent of their psychological state that you are declining to acknowledge or treat directly.

More specifically, if the physical sensation is caused by something physical, then this is really quite dismissive (from grandparent):

> there isn't really a great model of care for people who won't or can't believe that their ailment is psychological and requires psychological treatment

Maybe it's your problem that you won't or can't believe that the ailment might not be psychological.

> You, however, do seem to be dismissing it, by saying "nothing but anxiety". Anxiety is very real.

I am not dismissing anxiety in the least. I know more about it than I would like to, and yes it is very real.

>If someone is experiencing a physical symptom and you tell them it's not actually physical, that is dismissing it.

If you think diagnosing something as anxiety is the same as dismissing that person's experience and suffering and need for help, you're part of the problem.

It's dismissive if the cause is not actually anxiety.

Your entire argument only works if you accept the premise that this condition stems from anxiety alone. Since you have accepted this with what appears to be near certainty, then of course the rest of your argument makes sense to you, and your diagnosis of anxiety probably feels compassionate and sensitive.

To a person who does not share your confidence that anxiety is the only factor in play here, your dismissal of other possible factors is crazy-making.

Just acknowledging that there might be a factor here we don't fully understand would be enough. It's fine if anxiety is the best diagnosis and treatment plan given what we know right now. But the certainty that it's the entire story is off-putting.

You said yourself that depression/anxiety for physical symptoms are "diagnoses of exclusion, coming long after everything else has been exhausted." They are a fallback when you don't have another explanation. So why do you present a fallback diagnosis with certainty?

>If someone is experiencing a physical symptom and you tell them it's not actually physical, that is dismissing it

Nobody is saying that at all. The physical causes should be investigated, obviously. Suggesting to the patient that it might be psychological is not "dismissing" anything. Of course, it is true that most patients are vehemently opposed to the idea of psychosomatic pain, as well as many/most doctors. John Sarno's books are a fascinating read.

In this case there doesn't appear to be any pain, or physical sensation at all. You can't sense a "hole", any more than you can sense inflammation or the like.

I'm not familiar with Dr. Sarno personally, but I am familiar with New York's PM&R scene. I'd be mildly skeptical about things coming out of there. Not very skeptical, they're excellent doctors, but there's a strong strain of very-alternative medicine running in that particular sub-culture.

On the other hand, if you want a really mind-expanding read about the fuzzier edges of medicine, you might want to read Daniel Moerman's "Meaning, Medicine, and the 'Placebo Effect'." Don't let down your skeptical guard, but it's worth a read.

The whole "lived experience" folks are often overly self-important when they suggest that no-one can ever understand another person unless they literally are that other person because lived experience is the only thing that counts.

But there's some truth to that idea, just because you think you know what's happening to another person doesn't mean you actually do.

"dismiss"..."nothing but anxiety": Your question seems to imply that a psychological etiology is somehow less important than a physical etiology. Wouldn't the most important thing be developing a standard reproducible diagnostic criteria, then working on preventing or curing the problem? The parent comment seems to me to be a well-reasoned, nuanced description of the difficulties of dealing with this clinical scenario, and doesn't impose any value judgements regarding the 'intrinsic worth' of a medical symptom or etiology.

>> How do you explain the fact that this only appears to manifest when turbinates are reduced, and not as a result of any other surgical interventions on the nose?

By all fairness if you haven't had turbinate reduction it's going to be very hard to think you're suffering from a condition that is said to be caused by turbinate reduction.

> By all fairness if you haven't had turbinate reduction it's going to be very hard to think you're suffering from a condition that is said to be caused by turbinate reduction.

In all fairness, did you read the article? The patient suffered the symptoms first (before ever hearing of the syndrome), then went looking for an explanation, then found a syndrome exactly matching his symptoms linked to turbinate reduction, thought that was weird because he didn't think he'd had that, and only then saw "turbinate reduction" in the records from his surgery.

On the other hand its a standard procedure performed on many people. And if anxiety after surgery is common, then there is a good chance he will find enough people on the internet that they will already have formed a theory about this.

I had anxiety with panic attacks that had came with (for me) real physical (pain) experience for a few years. so I think that those people really need help, but not in the form of creating new disease-names for them. They need psychological treatment and maybe some physical 'placebo' treatment/surgery to cure them.

I got cured by telling myself over and over everything is okay, which felt like lying to myself.

Then why aren't we seeing a similar set of cases for other frequent surgeries that result in such debilitating pain as to drive people to suicide? I'm guessing we could look at appendectomies, gallbladder removals, wisdom tooth extractions, c-sections, etc - where are the similarly acute cases if it's purely anxiety unrelated to the specifics of the surgical procedure?

There are many. This is why many elective procedures associated with anxiety and depression now require psych evals before a surgeon will consent to do them, at least at more prestigious medical centers. You'll note if you go in for cosmetic surgery, lap band, gastric bypass, etc. many of these centers will ask for you to see a psych before proceeding.

Additionally, more anecdotally, have you ever visited the "alt med" internet? It's literally swarms of people with anxiety and depression obsessing over how random medical minutiae (related to their dental work, their lap-choli, etc.) explain their set-of-symptoms-that-are-typical-anxiety.

These "similar sets of cases" aren't hidden. They're ubiquitous. They just set themselves as opposed to (1) the idea that they might have a psychological illness, and (2) anything that smacks of "establishment" medical care (which they both view with anxiety and with disdain and hurt, because it was that establishment that does not take their complaints at face value.)

I read the article yes, thank you for checking.

And to be perfectly clear:

>> he didn't think he'd had that, and only then saw "turbinate reduction" in the records

So what? That's just something that was in the article. Who knows what really happened. Maybe the guy knew and he forgot about it (it's called cryptomnesia). Maybe the article misreports it. Maybe, who knows what. You can't draw firm conclusions by something someone said once.

Now can I check with you whether you read what you wrote? Because it didn't make any sense at all. How can anyone who hasn't had turbinate reduction think they have a condition that is caused by turbinate reduction? That does not compute.

> You can't draw firm conclusions by something someone said once.

The only people in this thread who are drawing firm conclusions are the ones expressing the firm conclusion that Empty Nose Syndrome is 100% attributable to anxiety.

I certainly don't claim to know what is going on. But I am not at all convinced by the people who are confidently dismissing the possibility of any other causes.

> So what? That's just something that was in the article. Who knows what really happened.

Even if I grant you that he might have unknowingly remembered that his surgery included turbinate reduction, that doesn't matter unless he knew about Empty Nose Syndrome before he experienced the symptoms.

> Now can I check with you whether you read what you wrote? Because it didn't make any sense at all. How can anyone who hasn't had turbinate reduction think they have a condition that is caused by turbinate reduction? That does not compute.

Here is why it computes. Empty Nose Syndrome, as described from various sources, has a common set of symptoms and is linked to one specific surgical procedure. Now let us suppose your theory is correct and it is caused solely by anxiety focused on the surgical intervention. If that were the case, you would expect many people to express this same set of symptoms from other nose-related surgeries. You would expect that the description of Empty Nose Syndrome would then expand to be linked to a number of different nasal surgeries. After all, if these patients are hypochondriacs whose anxiety causes physical discomfort, why would this anxiety be limited to only turbinate reduction?

Now maybe your theory is that awareness of the syndrome itself creates the power of suggestion that causes the patient to feel these symptoms. And without that and the intellectual link to turbinate reduction, they will not experience the symptoms. Now that theory is completely contrary to the story given in the article. But besides that, how under your theory did the syndrome begin? If it takes the power of suggestion to create the sensation, how did the first people experience it?

Anything that created this syndrome out of thin air for turbinate reduction should be able to create it out of thin air for other nose surgeries. And yet for 15 years it has continued to be linked specifically to turbinate reduction. Why?

First, please don't use "hypochondriac" - it's a horribly outdated term and no-one here is trying to diminish the suffering that people feel from this condition, even if they think it's somataform.

> Here is why it computes. Empty Nose Syndrome, as described from various sources, has a common set of symptoms and is linked to one specific surgical procedure. Now let us suppose your theory is correct and it is caused solely by anxiety focused on the surgical intervention. If that were the case, you would expect many people to express this same set of symptoms from other nose-related surgeries. You would expect that the description of Empty Nose Syndrome would then expand to be linked to a number of different nasal surgeries. After all, if these patients are hypochondriacs whose anxiety causes physical discomfort, why would this anxiety be limited to only turbinate reduction?

But these things tend to self limit. Ann says she has chronic fatigue. She undergoes some psychological therapy. She gets some relief from her symptoms. A bunch of people in the CFS organisation now shun Ann, and tell her that she didn't have real CFS.

I believe and trust that no one is trying to diminish the suffering. But within that I still feel there is condescension when someone describes the idea of investigating a person's symptoms as directly reported "Chasing down rabit-holes by pretending the anxiety is something /else/". There is way more certainty and dismissal in that attitude than anybody has justified in my opinion.

Don't get me wrong, I understand if investigating the direct symptoms might not be practical under some circumstances. But saying it's useless and "pretending" goes too far IMO.

> But these things tend to self limit. Ann says she has chronic fatigue. She undergoes some psychological therapy. She gets some relief from her symptoms. A bunch of people in the CFS organisation now shun Ann, and tell her that she didn't have real CFS.

I don't see how this scenario answers my question. Your story suggests that their is social pressure to resist the idea that the condition is treatable. It doesn't explain what would prevent an expanding scope for where the condition is identified.

Sorry but I can't keep up with you. You're trying to reason about things you don't even know happened, based on an account in an article you read on the internet, and on things that people report. That's no way to make sense of anything.

I'll give you an example. Where I come from, people believe in the Evil Eye: that if you stare at someone or something with a bad intention, if you're jealous etc, you can cause real, physical harm to that person, thing etc.

I've been accused of it a couple of times (I got scary eyes). Once a friend got a headache and then called her mom and asked her to say a special prayer people say that supposedly banishes the Evil Eye, then made a big todo about how a certain person always gave her the Evil Eye (it didn't take rocket science to figure out she was talking about me).

So, my friend obviously had an ailment, if you like: her head hurt. She felt bad, she blamed it on me. It helps that we were having an argument at the time it happened. We often had arguments. She often had headaches. She believed I was giving her the Evil Eye.

You can take the events themselves and try to reason about them. Did I give my friend the Evil Eye? Was the headache unrelated? Which happened first? What tells us they were cause-and-effect? What tells us they weren't?

Except, there is no such thing as the Evil Eye and you're basing your whole reasoning process on empty air- and convincing yourself that you're on firm ground.

The thing to ask is not "did I give my friend the Evil Eye?". The thing to ask is "is there such a thing as the Evil Eye?". Equally, you should be asking whether ENS is real in the first place. But you jump immediately in discussions of cause-and-effect, symptoms and accounts. If you're already convinced that ENS is real, those are not that important. But you have to ask yourself: why do you think it's real? Just because people say they have it? There doesn't seem to be anything else at the moment.

Like others say, I don't doubt for a moment that people suffer from - something. But I'm not convinced that it's what they say it is. I don't blame people for going mad about it, I do blame their doctors for not listening to them, but I don't blame ENS, because it sounds like the Evil Eye, or Morgellon's or whatever similar crazy thing people latch on to in their desperation.

And of course the worse thing is: by latching onto ENS (or whatever), people deprive themselves of the chance to have what ails them treated.

> If you're already convinced that ENS is real, those are not that important. But you have to ask yourself: why do you think it's real?

I don't know how many times I have to say it. I don't claim positively to know it is real.

I'm going to write it just once more so that hopefully you don't miss it this time: I don't claim to positively know that ENS is real.

Here is what I do know. Nobody on this thread has presented enough information to categorically deny that it exists. So if I see people who appear to be doing that, I'm going to call them on it.

>> Here is what I do know. Nobody on this thread has presented enough information to categorically deny that it exists. So if I see people who appear to be doing that, I'm going to call them on it.

That's not how it works. The side that makes a claim has to show that it's real. Everyone else has every right to doubt the veracity of the claim until that time. Otherwise we'd all be endlessly bogged down in pointless conversations.

Anyone can come up with a wild, fantastical idea. That doesn't mean everyone else has to waste their time trying to disprove it.

Btw, if you've made such a big todo just because you don't get that, I'll be a bit upset 'cause I've been wasting my time here.

> Anyone can come up with a wild, fantastical idea

The idea that a person's physical symptoms might have a physical cause is not wild or fantastical. By Occam's Razor it is (absent other information) the most likely explanation.

That's not Occam's Razor. That's an egregious misunderstanding of Occam's Razor. The simplest explanation is indeed that those people suffer from anxiety, which is a very common condition that covers all their symptoms, as others have said. You need to make too many assumptions to be convinced of the contrary.

First of all, because anxiety and depression are well known to manifest with physical symptoms. Which is why if you present with physical symptoms, anxiety and depression are diagnoses of exclusion, coming long after everything else has been exhausted. Notably, I didn't say they're /imaginary/ - just psychogenic. Anxiety is well known for significantly reducing the threshold for attention to stimulus: someone having an anxiety attack can feel things without somatic prompt, or they can feel something horrible with an underlying somatic prompt that, if they weren't having an anxiety attack, they'd never have even noticed. Generally people don't get brushed off as having mental disease. Although that's the popular narrative, again, (1) it's usually the last dx, and (2) even in these people's narratives, they go from physician to physician. Doctor after doctor looks at them and detects nothing.

This doesn't mean nothing is there, of course, but mystery illness is rare and anxiety is very common. It would be bad medicine to overlook the prevalent condition that explains your symptoms.

Second, post-surgical anxiety is quite common for a variety of conditions. I actually addressed it at the end of the post I suspect you didn't read. You presume this is somehow unique to turbinate reduction; that is an untrue assumption.

> I actually addressed it at the end of the post I suspect you didn't read.

Are all medical professionals (which I presume you are) this condescending, or just the ones on this thread?

> Anxiety is well known for significantly reducing the threshold for attention to stimulus: someone having an anxiety attack can feel things without somatic prompt, or they can feel something horrible with an underlying somatic prompt that, if they weren't having an anxiety attack, they'd never have even noticed.

Right. So how do you know that this isn't the result of a real physical stimulus that manifests primarily in anxious people because they are more sensitive to that stimulus?

How do you know that anxiety/depression are the "underlying issue", and not merely something that surfaces/amplifies the true underlying issue?

Everyone has slight physical discomforts. If it's being magnified tremendously, the magnifier is the problem.

> Would you similarly dismiss phantom pain and prescribe anti-depressants and CBT?

Well, there is good evidence that both antidepressants and CBT work for phantom limb pain, so yes...

Phantom Limb Pain: Mechanisms and Treatment Approaches, Subedi et. al., 2011