BMJ  2003;326:1092 (17 May), doi:10.1136/bmj.326.7398.1092

reviews

Book

Whiplash and Other Useful Illnesses

Andrew Malleson observes that "victimhood can bring much gratification." As he indicates, the high social status currently accorded to the victim is an important factor in the rise of "dissimulating disorders," in which patients present chronic physical symptoms for which no organic cause can be found.

American psychiatry recognises three categories of these disorders: malingering, factitious disorders, and somatoform disorders. Malingering is where symptoms are intentionally produced with the aim of securing tangible benefits. The problem is the difficulty of distinguishing malingering from factitious disorders, in which symptoms are intentionally produced but where there is no apparent external incentive and the motivation seems to be unconscious. These conditions are in turn difficult to distinguish from somatoform disorders, in which both symptoms and motivation appear to arise from unconscious processes. As Malleson observes, perhaps the essential difference depends upon the effectiveness with which the victim can "deceive himself and therefore others."

Malleson, a Canadian psychiatrist, discusses the "dissimulating disorders"—by any criterion one of the most important issues in contemporary medical practice—by focusing on the epidemic of whiplash neck injuries following minor car crashes. Through a comprehensive survey of the literature he exposes how doctors, alternative practitioners, scientists, lawyers, and patients have colluded in promoting a disorder that now afflicts millions and costs billions. While patients who sustain serious neck injuries have a good prognosis, minor collisions producing no demonstrable tissue damage now result in lifelong disability in around 10% of cases.

Malleson regards whiplash as a modern combination of the 19th century conditions of "railway spine" and hysteria. He locates it as one of a family of fashionable conditions, including fibromyalgia, repetitive strain injury, chronic fatigue syndrome, occupational back pain, chronic pain syndrome, and post-traumatic stress disorder, which the medical profession has offered patients who are, either consciously or unconsciously, seeking an escape from the pressures of modern life into the roles of sickness and victimhood. As he shows in this elegantly written and profound book, these conditions risk degrading medicine and bankrupting health services; they elevate junk science and corrupt the law; worst of all, they condemn patients to disorders from which there is little hope of recovery.

In one of his many aphorisms, Malleson captures the real menace of whiplash: "In perceiving a small auto collision as a cause of a persistent and disabling psychiatric disorder we diminish the calibre of our souls. We dissipate our human heritage of courage."

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Hackney, London fitz{at}easynet.co.uk

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Rapid Responses:

Read all Rapid Responses

"auto collision" victims deserve justice

Douglas J Carnall
bmj.com, 16 May 2003 [Full text]

Hysteria and other useful excuses

Gurli Bagnall
bmj.com, 16 May 2003 [Full text]

"Useful illnesses"

Derek J Stanley
bmj.com, 17 May 2003 [Full text]

Malleson, Fitzpatrick and the insurance industry

Gurli Bagnall
bmj.com, 18 May 2003 [Full text]

WHIPLASH IS THORACIC OUTLET SYNDROME

Carlos A. Selmonosky,MD
bmj.com, 21 May 2003 [Full text]

Book review "Whiplash and Other Useful Illnesses"; competing interests.

Derek J Stanley
bmj.com, 22 May 2003 [Full text]

No auto-insurance gold

Michael J Fitzpatrick
bmj.com, 24 May 2003 [Full text]

"Useful illnesses"

Corinne A Rees
bmj.com, 6 Jun 2003 [Full text]