Georg Ivanovas From Autism to Humanism - systems theory in medicine
Signs, symptoms and dysregulations are usually regarded as something accidental with no deeper meaning. They only inform us about some disturbances, but they have no value as such. Thus, one might make them vanish without any disadvantage. This approach can be called first order therapy.
First order therapies are characterized by the disappearance of the symptoms although the structure producing the symptom remains unchanged. A first order intervention has often an immediate and clear-cut effect. This makes this kind of therapy so seductive. It pleases doctors and patients when they think of the moment only and not of the future (Bleuler: 38). A typical first order therapy are steroids in asthma. They relieve and prevent crises, but do not change the development of the disease (chap. 5.5.b).
It was first systemic psychotherapy which developed a more detailed theory about how a symptom might have a stabilizing effect for the whole system, something that has been illustrated with the asthmatic child tying the family together (chap. 5.2). In such a case the treatment of an ‘identified patient’, that is, on the level of the symptoms, might have implications for other family members and lead to a series of further, unforeseeable complications. This shall be illustrated with the following case: A 5 years old boy diagnosed with ADHD was sent to me by a psychologist. He was extremely nervous and agitated. What impressed me most was that whenever the child found something that attracted his interest for more than one minute (e.g., the tap), the father intervened and forced him to sit down. This provoked a new cycle of crying, irritation and nervousness. Although I understood the regulative mechanism maintaining the symptom, I made the mistake and treated the child. Indeed, after 3 months the boy was about 50% calmer and made good progress in his language development. But during this time the father came home rarely (officially out of business reasons) and finally left the family. After the father had left, the mother stopped all therapies (with me and the psychologist), declared the child of having no problem at all, and from that day on mother and child lived closely together, even sharing the same bed. As I was told, the behaviour of the child deteriorated again. Although this development might be explained with other theories, as well, the therapy actually disturbed an inner stability and the situation got worse for probably all of the participants.
Such examples where the treatment of one sub-system leads to a disturbance of the whole system is often observed and is not restricted to ‘psychological’ diseases. A typical example is hormone replacement therapy which follows the pattern “works for symptoms but is not good for future health” (McPherson 2004).For example, women with migraine are less likely to develop breast cancer. Probably because of fluctuating estrogen levels (Mathes et al 2008). The treatment of migraine with a hormone replacement therapy might thus lead to a higher incidence of breast cancer.
A more disputable example is allergic disease where a slow development to more severe courses is observed. “First, asthma cases shot up, along with hay fever and other common allergic reactions, such as eczema. Then, pediatricians started seeing more children with food allergies. Now, experts are increasingly convinced that a suspected jump in lupus, multiple sclerosis and other afflictions caused by misfiring immune systems is real” (Stein 2008). Such a development can be regarded as a result of a continuous suppression..
Also everybody working in general practice or in the hospital knows such cases where during a treatment which started promisingly all of a sudden a whole series of ‘unrelated’ complications arise making no sense in the view of the previous positive course. This is a typical development of a network pathology. Everything seems to be smooth, but out of unclear reasons the situation deteriorates and becomes more and more complicated.
The meaning of a symptom, that is, the semantic structure bringing forth this symptom is rarely addressed in medicine. It is mainly Darwinian or evolutionary medicine which investigates the semantics of medicine. Evolutionary medicine starts with the premise that robustness is the product of billions of generations (Lenski et al 2006) and every network found in biological research makes only sense in the frame of evolution (Weitz et al 2007). For example, sickle-cell anaemia with a single copy of the defective gene confers immunity to malaria without causing sickle-cell anaemia (Lewin 1993). Here one person has to pay the price for the benefit of many others. Fever (discussed below) is a symptom where the same individual benefits.
From the evolutionary point of view, the intervention on the level of symptoms is seen rather critical. “A priori, it is unlikely that a cellular mechanism, which is the result of tens of thousands of years of evolution, will suddenly improve when an external 21st century chemical or other agent is introduced for completely unrelated reasons; such an agent is more likely to wreak rather than to prevent havoc” (Peto cited in Vandenbroucke 2004b).
Such first order therapies which lead to a deterioration of health have been called suppression by CAM. The term says: If a symptom is suppressed this might lead to more severe states not directly connected with the suppressed symptom. All this has been demonstrated above with the notions of rigidity and network pathology.
A practical example would be the suppression of gastric acid secretion by acid-suppressive therapy. This kind of therapy leads to a rise of the pH, such that viruses and bacteria persist in the stomach and the oesophagus which normally would have been eradicated. The result is an increased risk of community-acquired pneumonia (Laheij et al 2004) and other diseases (Dial et al 2006). As discussed earlier (chap. 2.6), a low iron level and anaemia are protective in inflammation. An intervention in order to correct the ‘deficit’ might cause more harm than good. That is, the symptom of anaemia has a meaning in a context of inflammation.
Another example is the treatment of fever with antipyretics. Normally fever is just regarded as an annoying side effect of many infectious and non-infectious diseases, only exhausting the patient. But evolutionary medicine sees it as important as all mammalians produce it (Berlim/Abeche 2001). CAM even postulates negative developments through its suppression. Although not overwhelming, the evidence supporting this view is growing:
These findings allow not yet the conclusion that the suppression of fever might lead to exponential runaways, but there is enough evidence to seriously consider this possibility.
All sorts of medical therapies could and should be investigated under this aspect of first order therapy and suppression. What are the consequences of such a kind of interventions? A typical first order therapy was the rigorous control of blood sugar in type 2 diabetics. But this kind of ‘central control’ had no health benefit (first order therapy) or let even to more deaths (suppression) than a more loose approach (Kolata 2008), probably allowing a more distributed control.