Running up against orthodoxy

There is much food for thought in Brian Martin's Dissent and heresy in medicine: models, methods and strategies:

An orthodoxy that draws on the full range of resources, namely which exercises unified domination, is incredibly difficult to challenge. Many challengers subscribe to the myth of scientific medicine as being based on open-minded examination of evidence, and thus handicap themselves, since in practice they are ignored or attacked. In order to have a chance, they need to understand that science and medicine are systems of knowledge intertwined with power, and that if their alternative relies entirely on knowledge, without a power base, it is destined for oblivion.

Strategies for dissidents and heretics are offered, including this advice:

Although rejection of dissent and heresy is the standard mode of operation of science, the establishment normally trades on a belief that ideas are treated on their merits... If challengers can reveal the reality, for example by showing that defenders of orthodoxy use double standards, lie, unfairly block publications, harass opponents, destroy documents, withdraw grants or dismiss researchers, this can lend credibility to the challengers and attract support for fairer treatment.

Book News

Hanif Kureishi kindly chose our book as his best book of the year.

The American edition is now advertised at Amazon (May 2008) with the title Why People Get Sick, and a very different cover.

The cover of the paperback of the UK edition (Feb 2008) is also advertised.

Another psychosomatic book

Jean Benjamin Stora, psychoanalyst and psychosomatician, head of teaching for Integrative Psychosomatics at the Faculty of Medicine at La Pitié-Salpêtrière (Paris), has written When the Body Displaces the Mind: Stress, Trauma and Somatic Disease.

When the human being is overwhelmed by excitations, tensions and frustrations, and the psychic apparatus is no longer able to absorb them because of its fragility and its weaknesses, it is the body that takes over.

Stora updates Freud's economic model:

This new psychosomatic approach fosters the economic and energic dimension of psychic functioning and its role in somatisations. In formulating the economic principle, Sigmund Freud referred to Carnot's theory in order to justify his viewpoint scientifically. Now, as Carnot's theory applies only to closed mechanical systems, it is no longer appropriate today; this book proposes replacing Carnot's theory with the 'open dissipative energy systems' theory (Ilya Prigogine) adopted in medicine and adapted here to the economic principle of psychoanalysis.

Naturally, the pitfall of dividing 'real' organic diseases from psychosomatic ones has been avoided:

In the context of this new approach, it is no longer a question of psychosomatic diseases but the role that the psyche plays in all diseases without actually being their cause. The psyche participates in the defence of both the organism and the immune system and it must be examined in relation to the somatic functions and organs.

Should be worth reading.

It's not what it used to be

As a busy term comes to a close, I hope to find more time for this blog now.

A couple of weeks ago my PhD supervisor, Donald Gillies, came to speak to our Reasoning group about Popper and induction. Knowing my interest in psychosomatic medicine, he brought me the details of a paper which had interested him:

Hallee JT, Evans AS, Niederman JC, Brooks CM, Voegtly JH: Infectious mononucleosis at the United States Military Academy. A prospective study of a single class over four years. Yale J Biol Med 3:182-195, 1974.

This is not available online, but a follow up is:

Psychosocial Risk Factors in the Development of Infectious Mononucleosis, S. Kasl, A. Evans, J. Niederman

It concludes:

Psychosocial factors that significantly increased the risk of EBV [Epstein-Barr virus] infection being expressed as clinical IM were: 1) having fathers who were "overachievers" (occupational status exceeding own educational level, or wife's education, or her occupational status); 2) having a strong commitment to a military career; 3) ascribing strong values to various aspects of the training and of military career; 4) scoring poorly on indices of relative academic performance; 5) having strong motivation and doing relatively poorly academically.

I was just thinking how university students might be good subjects for a similar study. However, tangible sexual behaviour seems to be the sole focus of today's researchers. In

A cohort study among university students: identification of risk factors for Epstein-Barr virus seroconversion and infectious mononucleosis. Crawford D H et al., Clin Infect Dis. 2006, Aug 1;43(3):276-82,

The authors conclude:

Our findings suggest that acquisition of EBV is enhanced by penetrative sexual intercourse, although transmission could occur through related sexual behaviors, such as "deep kissing." We also found that EBV type 1 infection is significantly more likely to result in IM. Overall, the results suggest that a large EBV type 1 load acquired during sexual intercourse can rapidly colonize the B cell population and induce the exaggerated T cell response that causes IM. Thus, IM could, perhaps, be prevented with a vaccine that reduces the viral load without necessarily inducing sterile immunity.

One day I'll write a book on changes in medical research.

The Definition of Disease

In her paper, Disease (2002) Studies in History and Philosophy of Biological and Biomedical Sciences. 33:263-282, Rachel Cooper defines disease as follows:

By disease we mean a condition that it is a bad thing to have, that is such that we consider the afflicted person to have been unlucky, and that can potentially be medically treated. All three criteria must be fulfilled for a condition to be a disease. The criterion that for a condition to be a disease it must be a bad thing is required to distinguish the biologically different from the diseased. The claim that the sufferer must be unlucky is needed to distinguish diseases from conditions that are unpleasant but normal, for example teething. Finally, the claim that for a condition to be a disease it must be potentially medically treatable is needed to distinguish diseases from other types of misfortune, for example economic problems and legal problems.

She is clearly rejecting more technical definitions, such as Boorse's 'interferences with natural functions' carried out by 'sub-systems of the body' for 'the overall aims of the organism', in favour of one couched in everyday language.

By ‘disease’ we aim to pick out a variety of conditions that through being painful, disfiguring or disabling are of interest to us as people. No biological account of disease can be provided because this class of conditions is by its nature anthropocentric and corresponds to no natural class of conditions in the world.

This definition makes an enormous difference when it comes to 'mental illnesses'. If one can be described in a way such that it is not construed as 'a bad thing', then it is not a disease. Cooper outlines Laing's account of schizophrenia:

According to this account it is us ‘normals’ who are truly alienated from ourselves. From childhood on we have been conditioned, first by our family, then at school, then at work, to act in ways that do not conform with our experiences, for example we are trained to be polite to people who offend us. Under such pressures we create a false self to present to the world. Schizophrenics are people who have refused to construct a false self and as such are better off than the rest of us. Their experiences are part of a healing spiritual journey that can potentially lead them away from normality and into a higher form of sanity. This account is also compatible with my own. Laing can be understood as claiming that schizophrenia is not a disease because it is not a bad thing and, if this were so, I would be forced to agree with him.

This conclusion is controversial to say the least, but it places our conception of what it is to thrive as a person at the heart of the matter, where it should be, rather than dressing it up in biological garb. Biology often puts in an appearance in the gaps where an author ought to be thinking in terms of ethics or politics.

A Dark Age For Mental Health

Darian wrote an article for The Guardian with this title.

Testing, John Ruskin and Alexis Brook

There's plenty of discussion going on at Kent about how and how much we ought to assess our students. Wouldn't they be better off being assessed less and having more of our time to teach them? Interesting then to see Ruskin taking up this question:

How many actual deaths are now annually caused by the strain and anxiety of competitive examination, it would startle us all if we could know: but the mischief done to the best faculties of the brain in all cases, and the miserable confusion and absurdity involved in the system itself, which offers every place, not to the man who is indeed fitted for it, but to the one who, on a given day, chances to have bodily strength enough to stand the cruellest strain, are evils infinite in their consequences, and more lamentable than many deaths. (Fors Clavigera, September 1871)

He reports there on a young man so eager to emulate Dürer or Turner that he "spent his strength in agony of effort; - caught cold, fell into decline, and died." Now we know 'scientifically' that exams take their toll. Back here I told you about wound-healing studies which showed that this process is delayed when students are in the midst of exams.

Someone else who understood psyche-soma connections was the psychotherapist Alexis Brook, whose obituary appeared in The Guardian yesterday.

[His] choice of career sprang from an experience he had with the Royal Army Medical Corps during the second world war. When the numbers of soldiers falling ill with malaria, dysentery and venereal diseases rose, he was afraid he would be castigated for not providing adequate medical care.

"To my surprise and relief, no one took any notice of me," he said later. The person who was on the mat was the battalion commander, who was asked to explain to his superiors what was wrong with his leadership that had caused such low morale." Viscount Slim, then commander-in-chief in Burma, was one of the few who recognised that these figures were indices of morale. If morale was high, fewer soldiers fell ill.

He was also interested in gut disorders, something I discussed back here:

After his retirement from the NHS in 1985, he became an honorary consultant psychotherapist at St Mark's hospital, Harrow. There, he highlighted the contribution a psychotherapist could make to the work of a hospital in dealing with disorders of the gut. His work was so successful that when he left, a post for a permanent consultant psychotherapist was established.

And he later turned to eye disorders. Ophthamology is an extraordinarily rich field for the psychosomatic approach to study. On pages 39-40 of our book, we say

Ophthalmology is a similarly isolated branch of medicine. Again, analysts and psychiatrists once received many referrals from ophthalmologists, yet today this would be bizarre. Despite the many hundreds of papers written and the detailed case reports which show the rationale and efficacity of such treatments, their usefulness has been forgotten. In 1960, it was reckoned that between 40 and 100% of recorded eye disorders were influenced by psychological factors. Intraocular pressure, for example, can be clearly associated with states of anxiety and emotional conflict, and so may affect conditions like glaucoma. This has never been disproved, but advances in medical technology have drawn attention away from it. Where talking therapies have been successfully used in conjunction with medication to reduce intraocular pressure, today drug treatments are applied almost automatically. Textbooks like Schlaegel and Hoyt’s once popular ‘Psychosomatic Ophthalmology’ have become historical curiosities. The amazing and detailed knowledge now available about the eye and its structure must seem much more appealing than psychological theories about unconscious factors in eye problems. And who can blame ophthalmologists for this?

How can Brook's legacy, in this field and others, be kept alive?

A Library at Last

Starting a new job entails complete immersion into the local ways of doing things. To convince myself I'm coming up for a gasp of air, let me jot something down. With a new academic post comes the thrill of exploring a new library and the chance of serendipitous discoveries of books from their different arrangement.

Yesterday I found myself by Ruskin's works, so took home for the evening the first volume of Fors Clavigera, his letters to the workmen of Britain. There I met up again with a passage I'd written down elsewhere.

I also took out Dr. Golem, the third book in the series by sociologists of science Harry Collins and Trevor Pinch. This continues their quest to get the reading public to realise what science is really like. Their history of resuscitation techniques is eye-opening. The changes in recommended practice from one decade to the next are frequent and dramatic, and there's little evidence that applied to heart attack victims that very much is achieved. Where ER, Chicago Hope and Rescue 911 show a long term survival rate of 67 percent after cardiopulmonary resuscitation, 1 to 2 percent might be more accurate in the real world.

The Usual Suspects

Two interesting posts at Science and Reason:

1) This one reports on research linking hostility, anger, and depression to inflammation. Remember that inflamation is implicated in all sorts of chronic diseases: heart disease, cancer, rheumatism, etc.

2) This one reports on the link between stress and weight gain.

While researching for the book we read endless studies of the sort discussed in these posts. There really is a very impressive body of research now which links psychological traits and experiences with health-related physiological changes.

However, what we come back to time and again is our sense of disappointment with what we consider to be the overly simplistic psychology of this kind of research. When you come to look at them closely, constructs like 'stress' and 'hostility' just can't be made to do the work required of them. Let's return 'stress' to its natural home - helping us think about whether bridges and the like are liable to collapse.

Philosophy of Medicine

During my first year in Kent I'll be teaching the courses of someone on leave: Philosophy of Science, and Logic. What I'll need to do over this year is put together my own courses for future years. Something to do with mathematics, but what will no doubt prove more popular is a Philosophy of Medicine course. I'll use this blog over coming months to jot down thoughts about such a course.

An initial impression is that the field is dominated by bioethics. I'd rather spend some time on other topics: medicine as science, the nature of the medical subject, the nature of illness/disease/wellness, etc.

Some initial references:

Articles
An introductory course in philosophy of medicine, A Rudnick

Philosophy in the undergraduate medical curriculum— beyond medical ethics, R Meakin

Philosophy for medical students—why, what, and how, P Louhiala


Books
The Philosophy of Medicine: Framing the Field by Hugo Tristram Engelhardt

Enigma of Health: The Art of Healing in a Scientific Age by Hans-Georg Gadamer


Journals
Journal of Medicine and Philosophy

Philosophy, Ethics, and Humanities in Medicine

Back from Tuscany

Ruskin writes somewhere that you must love the climate you live in. Returning to a blustery, showery Yorkshire from sun-bathed Tuscany certainly puts this love to the test.

A story I heard while there: A woman in her late sixties has suffered from serious skin complaints on her elbows for many years. Pills and lotions of all sorts are offered, but make little difference. Her six-year old granddaughter noticing these livid sores tells her grandmother she wants to kiss them better. Now, naturally, the woman can't think that this beautiful girl wants to press her lips against such loathsome skin. But the girl insists. Within days the elbows are obviously much better, and this improvement proves to be not merely temporary.

I was put in mind of those fairy tales where a freely given kiss is required to transform something hideous to its former state. Interesting how these stories change. The original Grimms' tale of The Frog Prince has the princess hurling the frog against a wall in disgust. It would be fascinating to chart the different versions of this tale. The Brothers are known to have removed sexual content and included violent content in their adaptations.

News

Posting is going to be fairly sparse until the autumn. But here are four reports which might be of interest:

1) I've mentioned research on cortisol levels in foetuses correlating with the mother's state of mind. Now it appears this may be a mechanism which disturbs infants' sleep, and this is known to have physiological consequences.

2) People may get 'real symptoms' from worrying about phone masts.

"Belief is a very powerful thing," said Professor Elaine Fox, of the University of Essex, who led the three-year study. "If you really believe something is going to do you some harm, it will."

3) Identification may be an important factor in determining obesity levels. When family members share a condition, genes are often reached for. In our book we suggest this may lead us away from thinking in terms of identification. Now, some research suggests that having an overweight friend may influence your own weight.

4) Can pets detect when people are soon to die? Strangely, the attending doctor is reported as limiting the perceptive cat's options to a 'biochemical explanation' or 'being psychic'. Can't a cat pick up behaviour?

The Low Season

I'm busy preparing four papers at the moment, including one for a workshop on 'mathematics and narrative' in Delphi next week, along with two grant proposals. It would probably be more efficient to do this sequentially rather than in parallel, but deadlines force the issue.

So not much time for psychosomatic medicine. I'm mulling over some thoughts about this idea that paediatric medicine needs to be based on studies of children, rather than than assuming they're little adults. An appropriate thought for those adopting the psychosomatic approach too. You may recall that experimenters found it easier to remove warts by suggestion in prepubescent children rather than older subjects.

Thin pickings then, but I see the Hay Festival organisers have put material online, so you tune in to Darian and my presentation here.

After those statistics

After the observation that assessment for heart disease based on a study of an American town named Framingham overestimated the risk for men in Britain, and men and women in Germany, we now have a more accurate risk score called QRISK. The authors, however, note that

since the validation was performed in a similar population to the population from which the algorithm was derived, it potentially has a "home advantage." Further validation in other populations is therefore required.

One good place to try it out would be Hungary, which has surprisingly high rates of coronary death. 'Social distrust' and 'rival attitude' seem to be key factors.

After those statistics, try an interview with James Lynch, author of the excellent Broken Heart. One day I'll take a look at The Language of the Heart: The Body's Response to Human Dialogue and A Cry Unheard: New Insights into the Medical Consequences of Loneliness.

Genes and Disease

In our book we quote David Weatherall, the director of the Institute of Molecular Medicine at Oxford University, saying

When scientists announce that they have discovered a ‘gene’ for heart disease or asthma, what they really mean is that they have identified one of a number of genes that may, under certain circumstances, make an individual more or less susceptible to the action of a variety of environmental agents, some of which are known to be involved in our common intractable diseases.

It appears now that molecular biology is going through some profound changes, which will make those simplistic 'one gene - one disease' stories even less believable.

It is beginning to dawn on biologists that they may have got it wrong. Not completely wrong, but wrong enough to be embarrassing. For half a century their subject had been built around the relation between two sorts of chemical. Proteins, in the form of enzymes, hormones and so on, made things happen. DNA, in the form of genes, contained the instructions for making proteins. Other molecules were involved, of course. Sugars and fats were abundant (too abundant, in some people). And various vitamins and minerals made an appearance, as well. Oh, and there was also a curious chemical called RNA, which looked a bit like DNA but wasn't. It obediently carried genetic information from DNA in the nucleus to the places in the cell where proteins are made, rounded up the amino-acid units out of which those proteins are constructed, and was found in the protein factories themselves.

All that was worked out decades ago. Since then, RNA has been more or less neglected as a humble carrier of messages and fetcher of building materials. This account of the cell was so satisfying to biologists that few bothered to look beyond it. But they are looking now. For, suddenly, cells seem to be full of RNA doing who-knows-what.

There follows a description of the different jobs performed by RNA. Then,

...evolution is as much about changes in the genes for small RNAs as in the genes for proteins—and in complex creatures possibly more so. Indeed, some researchers go further. They suggest that RNA could itself provide an alternative evolutionary substrate. That is because RNA sometimes carries genetic information down the generations independently of DNA, by hitching a lift in the sex cells. Link this with the fact that the expression of RNA is, in certain circumstances, governed by environmental factors, and some very murky waters are stirred up...What is being proposed is the inheritance of characteristics acquired during an individual's lifetime, rather than as the result of chance mutations.

It remains to be seen though whether medical researchers take this opportunity to rethink the complexity of the human organism as a physical, personal and social being, or whether another bout of reductionism ensues.

Drowning in data

I watched this talk yesterday given by Jeff Hawkins, someone who has worked on many well-known pieces of technology, but whose real love is the brain. I was struck by his thought that neuroscience suffers from a surfeit of data and a dearth of theory. Researchers act as though simply accumulating more data will solve their problems. Hawkins' own take on the mammalian brain is that we shouldn't think of it in terms of sensory input and behavioural output, but rather understand it as a prediction device.

Psychosomatic medicine seems to be following the neuroscience approach, a largely atheoretic accumulation of 'facts'. You can see this from recent editions of what was once the flagship journal, Psychosomatic Medicine.

Goldfish Research

I'm not sure if the research has been done, perhaps it's merely to assuage the guilt of their owners, but goldfish are often considered to have very short memories. One circumnavigation of the bowl and they forget that they've already encountered that plastic anchor.

Sometimes it seems that research along psychosomatic lines is goldfish-like. Take this article, 'A qualitative exploration of the Couvade syndrome in expectant fathers' by Brennan et al., reported here, and announced here. The Couvade syndrome (beware the use of 'psychomatic' in this Wikipedia article) is a condition in which the father of a foetus experiences some of the symptoms of pregnancy - pains, cravings, nausea, etc.

The couvade's been studied for a long while now, psychoanalytically and anthropologically, but in phenomena like this it never seems that much progress is perceived to have been made. Largely I would attribute this to researchers' shifting sense of the right way to do psychology. This abstract may depict the 'right' way to do things now, but one turn about the bowl earlier or later and it seems right to do something completely different.

The aim of this qualitative study is to explore the nature and duration of male partner's somatic and psychological symptoms, across gestation and parturition, collectively called the Couvade syndrome. Fourteen men with expectant partners aged 19-48 years from diverse social and ethnic backgrounds were interviewed. The data was processed using qualitative analytical software WinMAX Professional and the emerging themes and sub-categories identified and analysed. The first was 'Emotional Diversity in Response to Pregnancy', which varied with time and other factors and also included mixed and polarised feelings such as excitement, pride, elation, worries, fears, shock and reluctance. The second was 'Nature, Management and Duration of Symptoms', which revealed the types and duration of physical and psychological symptoms experienced by men. Attempts at managing these were influenced by social and cultural factors. Physical symptoms were more common than psychological ones, and their time course demonstrated trends similar to those reported for the Couvade syndrome. Although the former were reported to their GPs, no definitive diagnosis was made despite medical investigations being performed. The third theme, 'Explanatory Attempts for Symptoms' was influenced by cultural beliefs and conventions like religion, alternative medical beliefs or through the enlightenment by healthcare professionals in the process. Some participants were unable to find explanations for symptoms but some perceived that they were related in some way to the altered physiology of their female partners during pregnancy. These findings highlight the need for further research to acquire deeper insight into men's experiences of, and responses to, pregnancy as a way of explaining the syndrome.

References:

Reik, Theodor (1914) 'Die Couvade und die Psychogenese der Vergeltungsfurcht', Imago, 3, 409-455.

Robert L. Munroe, Ruth H. Munroe, John W. M. Whiting (1973) 'The Couvade: A Psychological Analysis', Ethos, Vol. 1, No. 1, pp. 30-74.

Portuguese Interview

You can read an e-mail interview I gave to a Portuguese journalist here.

What patients want

It's a start, I suppose, researchers trying to find out what patients want from a first medical encounter with regard to hand-shaking and whether to use first name, second name or both.

78% of patients want their hand shaken. But how do you know which 78%?

Changes in the psychological environment

I've just reached the part in Dickens' Dombey and Son where the young Paul Dombey passes away. This revived a thought in me I've been pondering for some time. The improvement in the nation's health from the nineteenth to the twentieth century is largely attributed to improvements in nutrition and hygiene rather than to medical advances. Deaths from childhood illnesses such as measles were declining long before vaccinations were introduced. But, if we take the thesis of our book seriously, we should wonder whether changes in the psychological life of the child and adult were involved too.

If early death from heart disease could be staved off by familial and communal cohesion in Roseto, shouldn't we expect the kinds of psychological environment prevalent in Victorian England, at least as described by Dickens, to be positively damaging? Of course, Dickens is prone to caricature, but across all classes there's an abundance of lovelessness. Would the son have survived had Dombey senior known how to love him well as a father?

Cortisol and the Baby

In my third post I mentioned research looking at how a mother's life situation affects cortisol levels in the foetus. From a report on a new study we learn that a correlation between their respective levels of this hormone is measurable at 17 weeks of gestation.

An earlier study, published in January and led by Prof Glover, measured the intelligence of more than 100 babies and toddlers whose mothers had suffered unusually high stress in pregnancy. It found their IQ was generally about 10 points below average, and that many had higher than average levels of anxiety and attention deficit problems. Relationship problems with a partner were the most frequent cause of stress for pregnant women, the research revealed

Perhaps Aristotle was right. Don't argue around pregnant women.

The Woodstock of the Mind

This was Bill Clinton's description of the wonderful Hay Festival. It's held every year in the tiny Welsh town of Hay-on-Wye, packed with the kind of excellent second-hand bookshop that used to be so common 30 years ago.

Just like at Woodstock, heavy rain had turned the fields to mud. Fortunately, to keep our minds dry all the events took place under canvas. Darian and I spoke about our book to an audience of around 700 people for about an hour, including time for some very pertinent questions. An excellent event. And we got to stay in the same hotel as Tony Benn and Peter Falk!

Darian had spotted an interesting detail in the report on Roseto I mentioned a while ago. Remember that Roseto was the socially cohesive town of descendants of Italian immigrants, where early death from heart disease was non-existent. It turns out that an indication of the breakdown in this cohesion was "when the town's coronet band, founded in 1890, demanded for the first time to be paid for playing at the church's big festival". This was observed in The Power of Clan: The Influence of Human Relationships on Heart Disease (1992) by Stewart Wolf and John G. Bruhn, a follow up to their The Roseto Story—An Anatomy of Health (1979).

When will we learn that health and politics are inextricably linked, and act on this?

More on IBS

I've mentioned Irritable Bowel Syndrome here before. This month an article has appeared in the British Medical Journal which claims that

The medical management of patients with irritable bowel syndrome is often unsatisfactory. Doctors are still taught that irritable bowel syndrome is a diagnosis of exclusion, and patients readily sense that they are being told that nothing is really wrong with them. Many people soon come to appreciate that the range of medical treatments available is limited in both scope and efficacy. The mood of negativity, once established, is difficult to dispel.

The BBC report on this article has one of the authors, Dr. Ian Forgas, saying

Patients with irritable bowel syndrome should be made aware of the existence of these treatments so that they can make informed choices.

Specifically, they should be made aware that using a psychological treatment does not mean that the disease is 'all in the mind'.

Nick Read, with whom I appeared at the Ilkley Literacy Festival, is quoted there:

There's now a lot of evidence that psychological therapies can be effective, but a lot of doctors remain sceptical, and carry on treating with drugs which have side-effects, and which basically don't work.

I work with patients with IBS trying to understand what, for each patient, lies behind the illness.

The BMJ report also quotes Hippocrates:

It is more important to know what sort of person has a disease than to know what sort of disease a person has.

Imagine taking that seriously!

News

Hooray! A permanent academic post at last. I'll be starting in the philosophy department in Canterbury, Kent in September.

Next week Darian and I are speaking about our book at the Hay-on-Wye literary Festival.

Meditating on health

A study finds that practicing yoga leads to an increase in the brain transmitter gamma-aminobutyric acid (GABA), associated with a feeling of relaxation and a lessening of anxiety.

In our book we mentioned work by Richard Davidson on the effects of mindfulness meditation on immune response to 'flu vaccine. After an 8 week course subjects were vaccinated and found to have a significantly stronger response than controls. Differences also showed up in brain activity, with greater left-sided anterior activation.

Davidson jointly edited a book Visions of Compassion, whose subtitle - Western Scientists and Tibetan Buddhists Examine Human Nature - explains its contents.

Broom review

I posted about Brian Broom's book Meaning-Full Disease a while ago. You can read a review of it at the Heroes Not Zombies blog.

The Biopsychosocial model

I'm a little busy at the moment preparing for an interview, so posts won't be so frequent for a few days. In the mean time, readers might like to take a look at this paper: Medically unexplained symptoms: the biopsychosocial model found wanting.

On the face of it, the biopsychosocial model might sound as though a way had been found to overcome mind-body dualism. Taking a systems theoretic stance, we can view the individual as a biological organism, with a personal psychology, participating in a society.

As the authors argue, however, the use of this model in practice reinforces dualistic thinking. If no biological pathology is found in a patient, the illness is taken to be psychologically or societally induced, and the patient brought to understand that they have misrepresented the system level relevant to their disorder.

On the authors' view,

Rather, clinicians have an important role as experts in the process of helping patients interpret and make sense of their pain as part of their legitimate experience of the world, and, as such, the interpretivist view provides a more satisfactory philosophical rationale for a patient-centred clinical method.

Alcohol abuse

There has been some debate as to whether those in the medical profession are more likely than the average population to abuse alcohol. This article in the Student BMJ suggests the evidence is inconclusive, but does note a culture of ritualised drinking games in certain medical student cohorts. Even if alcohol abuse were no higher than in other comparable professions, it would still represent worryingly high levels of consumption.

Now, perhaps medical professionals are better than most in not allowing their drinking to endanger others, in view of the obvious risks of malpractice. However, evidence from Spain shows that a higher proportion of medical professionals there are drink-driving.

In our chapter of the psychology of doctors, we discuss the question of whether medical training and practice puts an unusual strain on doctors. We suggest that the source of the problem lies earlier. This report comments on a study published in 1972 which agrees

that alcohol and drug use among physicians was related to life adjustment (e.g., unstable childhood) difficulties before medical school.

Unfortunately, this type of detailed study of the lives of a sector of the population are much rarer today.

The Perils of Retirement

One can't help wondering sometimes if they knew more in the eighteenth century about the causes of ill health than we do now. Turning once again to Sterne's Tristram Shandy, we read:

No body, but he who has felt it, can conceive what a plaguing thing it is to have a man's mind torn asunder by two projects of equal strength , both obstinately pullling in a contrary direction at the same time: For to say nothing of the havoc, which by a certain consequence is unavoidably made by it all over the finer system of the nerves, which you know convey the animal spirits and more subtle juices from the heart to the head, and so on - It is not to be told in what a degree such a wayward kind of friction works upon the more gross and solid parts, wasting the fat and impairing the strength of a man every time as it goes backwards and forwards. Vol IV chapter 31

This, at an unconscious level, is not a bad description of the consequences of living a contradiction.

But what if one runs out of projects? How will this affect health? Well, it seems that some ex-American football players have this precisely this problem after retirement. A study reports that many ex-NFL players suffer from pain and depression. Further correlations are then found with sleep problems, lack of exercise, and financial difficulties.

But which way around is it best to take the causal flow? It is pleasing to see one of the study's researchers viewing things our way. Thomas Schenk claims:

On retirement, athletes have reported jarring transitions to a life in which the focus of such intense commitment is unclear, the resources and personnel that organized and managed their lives away from the competition venue are lost, and the rewards, both emotional and financial, are diminished.

A retired Detroit Lions player, Eric Hipple, was also on the team as an outreach coordinator for the University of Michigan Depression Center. It would be interesting to know how he, as someone with a purpose in life, is faring.

Retirement also featured in the latest findings of the Whitehall II study. This long term research programme has carefully studied British civil servants for over twenty years, finding that those of lower rank are significantly more likely to suffer from many of the major chronic diseases, and have higher mortality rates for these diseases, than their higher-ranked colleagues.

Now, Tarani Chandola and colleagues have found that this discrepancy only worsens after retirement.

The average physical health of a 70 year old man or woman who was in a high grade position was similar to the physical health of a person from a low grade around eight years younger. In mid-life, this gap was only 4.5 years. Although mental health improved with age, the rate of improvement is slower for men and women in the lower grades.

Speculations concerning this discrepancy mention the ability to purchase better food and to have a more active social life. It would be interesting to approach this cohort in the same terms as those Schenk used in the quotation above.

Sterne had an excellent solution for his character Uncle Toby's retirement - to re-enact the major sieges of Flanders on a rood and a half of what had been his bowling green as they were freshly reported. The only flaw in this scheme, however, was that it left poor Toby vulnerable to the Peace of Utrecht.

The common good

More warnings about modern life causing high blood pressure, which in turn brings about cardiovascular disease. One in four adults already has the condition, but, the report warns, in 20 years time, if nothing is done that figure could rise to 2 in 5. So why are we moving ever further away from the conditions which prevailed in Roseto in the 1950s?

Let's consider how the problem and its solution are framed. One researcher from the London School of Economics claims

Uncontrolled high blood pressure among people in their 30s, 40s and 50s will inevitably lead to an increase in cardiovascular disease and stroke that will strike down men and women at the height of their earning power, potentially turning them from drivers of economic growth and sources of public revenues to long-term recipients of extensive social benefits with increased healthcare needs.

The problem, then, is not just one of individual ill health. It effects us all. But notice how we transcend the individual only to the extent of worrying how others will become economic liabilities for us. Wouldn't an inhabitant of 1950s Roseto have used a different vocabulary? Wouldn't we have heard them worry that ill health might prevent people from participating in the life of the community?

Last month I was invited on to Radio Leeds to discuss the book. Thinking back about the questions I was asked by the DJ, what was so striking was how they were informed wholly by the modern conception of 'self help'. If, as we suggest, the way people worry matters to their health, what can someone do about it? My responses were so many ways of resisting the 'self help' construction.

The idea that the solution rests with the individual appears again in reactions to the high blood pressure study. We must each 'choose a healthier lifestyle'. How far we are from a political conception of a society organised in terms of the common good, and the individual citizen's good lying in that common good. But even when that political conception prevails, it is no easy matter to protect it from others which govern neighbouring communities. Returning to Roseto, what led to its demise was that a component of the common good was the aim to enable the next generation to achieve a 'better' life through a college education. It is not hard to imagine how this could bring about the dissolution of communal life. That the only islands of self-sustaining communal life in the West occur in groups such as the Amish suggests how radically different the political organisation of such communal life may have to be.

Now I wonder what blood pressure levels are found amongst the Amish.

What cannot be written

I commented on the changing style of the articles appearing in the journal Psychomatic Medicine back here. Perhaps to many interested in medical psychology, the psychological hypotheses of fifty years ago seem somewhat speculative, possibly even hopelessly uncontrolled. But can anyone read these studies today without being struck by the originality of the researchers, expressing ideas which would be impossible even to formulate in contemporary journal language?

Take the April 1957 edition, and two papers more or less at random. In Human Camouflage and Identification with the Environment: The Contagious Effect of Archaic Skin Signs, we read:

One of my patients experienced a renewal of eczema of the hands only when childhood fantasies of choking his brother returned.

and

In several patients with an emotional skin rash I found the Bible story of Jonah and the whale repeatedly appearing in their dream life as a panicky, ambivalent fantasy of skin delight and skin destruction while living in a fantasy womb.

Has the exclusion of this kind of observation been an unmitigated triumph of scientific progress? Ditto for the disappearance of the kind of collaboration between a psychiatrist and surgeon described in Rectal Resection: Psychiatric and Medical Management of Its Sequelae; Report of a Case?

Our book in the blogosphere

Lisa Appignanesi has posted her Observer review of our book on her new blog.

Bob Leckridge, a GP from 1982 through to the end of 1995, since when he has worked at Glasgow Homeopathic Hospital has this to say about it on his blog - Heroes Not Zombies.

Thinking about the heart

At some point we'll need a neurology which can tie in with what a narrative-style psychology has to say about ill health. We should never underestimate the difficulty, however, of wedding together such different languages.

Perhaps first we might expect detailed findings relating brain functioning to disease. The BBC reports some research suggests that heart functioning is represented in 'higher' levels of the brain, in the cerebral cortex. Feedback loops were found to operate when heart disease patients were asked to perform mildly 'stressful' tasks, such as counting backwards in sevens. This gives us a clue as to how heart activity can be destabilised, leading to arrhythmia and even sudden cardiac arrest.

What we'd really like to know is how higher level cognitive processes influence and are influenced by heart activity.

Evidence-based Medicine

Advocates of 'Evidence-based Medicine' have been able to point to many forms of medical treatment for which there is no evidence for their efficacy. Recently it has been suggested that in many medical units between 15% and 20% of treatments offered are completely unsupported.

When we consider its history, it is perhaps unsurprising that a practice such as medicine should have components which have not received the careful scrutiny of the modern clinical trial. In many cases we should welcome questioning of apparently well-established practices. For instance, some of the most important findings are against unnecessary surgical interventions, such as hysterectomies.

But should we accept unreservedly a drive whose aim is to analyse each treatment into its component parts and submit each to a test approximating the gold standard - the prospective randomized double-blind placebo-controlled clinical trial?

Well, not if it means that treatments which cannot be tested in such a way are automatically devalued. And isn't this precisely the case where there is a psychotherapeutic component to the treatment programme? While researching our book, we came across studies which attempted to apply 'placebo psychotherapies', but in doing so they reveal how little their authors understand psychotherapy to try to force it into a model of something active or inactive and applied in a fixed number of doses.

And what of the wart remedies I mentioned? Doesn't the ideal of a placebo-free effect act to discourage researchers from exploring the fascinating phenomenon itself?

Balint groups

From a 2006 editorial of the Journal of the Balint Society:

If our Society was asked to redesign the GP curriculum we should be in no doubt about the priority. We would wish to help our young doctors to understand the importance of the emotions in clinical practice; to be aware of their own feelings as well as those of their patients and to be able to manage those emotions without being overwhelmed or disabled. We would provide this education by offering at least a year of Balint group experience to all trainee family doctors. After all this can be done in Germany and increasingly it is happening in the USA. Why couldn't it happen here, in the land where Balint groups began?

Why indeed? Back in 1970, Marshall Marinker made the following suggestion with regard to diminishing numbers of GPs attending Balint groups:

...it is not the logistic difficulties, but the massive psychological resistances that stands in the way of the growth of seminar training. The work involves doctors in exercises which have become alien to their habits of thought. (p. 84)

Journal of the Royal College of General Practitioners 1970; 19(91): 79-91

Are these resistances still in place? Back to the editorial:

There is still a subterranean prejudice against Balint which lurks in the minds of many GPs. These doctors view the idea of doctors sitting round in a group discussing their feelings with suspicion and distaste. The phrase 'navel-gazing' crops up. The practice encourages too much introspection and fruitless speculation. It can't be healthy. These doctors should get out in the fresh air more often.

Perhaps prejudices can be reduced by hearing of other countries' experiences. For example, a small sample of Swedish GPs were found to have benefited from group participation:

In this study, we examined Balint group participants' sense of control and satisfaction in their work situation and their attitudes towards caring for patients with psychosomatic problems. Forty-one GPs filled in a questionnaire with a 10-point visual analogue scale. Of these, 20 had participated in Balint groups for more than one year and 21 were a reference group. The Balint physicians reported better control of their work situation (e.g. taking coffee breaks and participating in decision making), thought less often that the patient should not have come for consultation or that psychosomatic patients were a time-consuming burden, and were less inclined to refer patients or take unneeded tests to terminate the consultation with the patient. These results might indicate higher work-related satisfaction and better doctor-patient relationship.

Balint wouldn't have liked the use of 'psychosomatic' to designate a type of patient rather than a style of approaching the medical encounter, and he might have thought it a little strange to gauge a GP's 'control of their work situation' by their ability to take coffee breaks, but I suppose we must be grateful for any positive news.

Brian Broom

Brian Broom is a consultant physician and psychotherapist working in Christchurch, New Zealand. While researching our book I came across his Somatic Illness and the Patient's Other Story, which places particular emphasis on patients suffering from allergies and rashes. Now he has a new book out Meaning-full Disease.

From an article he has written about the book in the Karnac Review:

Z. was referred to me having suffered eight-twelve mouth ulcers continuously for five years. There was no satisfactory medical explanation or treatment. I asked her my 'smorgasbord question': 'What was the most interesting, significant, troublesome, problematic, difficult, stressful, worrisome, frustrating, or hard thing that hapened around the time this problem started?' She said that the ulcers began around that time that her daughter left the Roman Catholic Church. After a moment's silence I asked her what was the hardest thng about that? She said: 'I can't talk to her about it.' I suggested that she talk with her daughter; she did so, and the ulcers disappeared.

Here is the NHS Direct article on the condition. They recognise the role of 'stress' in promoting ulcers, but in the usual problematic way (see here and second comment here):

Try to avoid getting run down by making sure you eat a balanced diet, take regular exercise and learn to manage stress. Make sure your teeth are in good order by regular visits to your dentist.

If you are prone to recurrent ulcers, avoid damage to the inside of your mouth by using a softer toothbrush and avoiding hard, brittle, or sharp-edged foods.

Broom writes an interesting comment about how patients often did not do so well when he referred them to non-medical psychotherapists:

The problem seemed to be that the psychotherapists distanced themselves from the patients' physicality: they often would not respond to patient talk about physical symptoms; most did not feel entitled to discuss bodily issues; typically they suggested that patients discuss physical symptomes with their doctors, effectively silencing any psychosocial exploration of symptoms.

Mind-body duality is writ large in the organisation of health service provision.

When challenged on this, clinicians typically defend themselves on a variety of grounds. Some stand strong in a dualistic scepticism regarding the relevance of mind or body to their respective disciplines. Others protest a lack of skills in one territory or the other: the 'scope of practice' defence. Yet others, constrained by time, perceived priorities, sensitivity to power structures and systems, and by 'ethical' obligations to confine themselves to that which they have been trained in, will protest that a more holistic approach to the patient is impractical. Others simply take the opportunities granted those willing to conform to the dualist and reductionist structures of power and reward within medical and psychotherapeutic culture, and frequently profess no idea as to what we are talking about. Thus, an unbiased observer might conclude that the mindbody clinical problem is really about doctors and therapists, their favourite models, their institutional structures, and where the power lies, rather than the needs of patients.

Powerful stuff! As we note in our book, this dualistic way of thinking may find its echo in the patients themselves, when unprocessed thoughts and emotions provide conducive conditions for physical symptoms. On the other hand, large numbers for whom medical dualism is unsatisfactory are seeking out alternative treatments.

Unemployment and Natural Killer Cell Cytotoxicity

Natural Killer (NK) cells are part of the innate immune system, the evolutionary older, non-adaptive part of our defences. They are involved in protecting us when our own cells are damaged, say, by viral infection or if they begin to form a tumour. They are described as cytotoxic, that is, toxic to cells.

A recent paper in Psychosomatic Medicine, Immune Function Declines With Unemployment and Recovers After Stressor Termination, looks at the results of measurements on the cytotoxicity of NK cells (NKCC) during periods of unemployment. NKCC was found to be significantly higher in the employed. Especially interesting was the finding that NKCC levels in the 25 unemployed who found work during the study recovered significantly.

Of course, it would be interesting to know more about the effects of personal job satisfaction and job security on immune functioning for a fuller picture. Then there are the effects of retirement, often a dangerous time for people.

Wound Healing

In Chapter 1 of the second volume of The Life and Opinions of Tristram Shandy, Gentleman, uncle Toby is recovering at Tristram's father's house after receiving his wound in the groin at the seige of Namur. To keep him occupied through the four years of his recovery, visitors come to listen to his military exploits during that campaign. Unfortunately, however, uncle Toby is wont to get his military engineering terms all mixed up, causing him great vexation.

No doubt my uncle Toby had great command of himself, - and could guard appearances, I believe, as well as most men; - yet any one may imagine, that when he could not retreat out of the ravelin without getting into the half-moon, or get out of the covered way without falling down the counterscarp, nor cross the dyke without danger of slipping into the ditch, but that he must have fretted and fumed inwardly: - He did so; - and these little hourly vexations which may seem trifling and of no account to the man who has not read Hippocrates, yet, whoever has read Hippocrates, or Dr James Mackenzie, and has considered well the effects which the passions and affections of the mind have upon digestion, - (Why not of a wound as well as of a dinner?) - may easily conceive what sharp paroxysms and exacerbations of his wound uncle Toby must have undergone upon that score only.

Mackenzie (1680-1761) was a Scottish physician, and author of The History of Health and the Art of Preserving it (1758).

Sterne's hunch is backed up by contemporary research. On page 239 of our book we mention a study which showed that when holes were punched into the roof of the mouths of dental students, on average the wound took 40% longer to heal during a period prior to examinations than during a vacation period.

Uncle Toby's condition starts to improve when he draws up a map of Namur, and immerses himself in the theory of military engineering until he is quite fluent. The cure gains enormously when he removes himself to his country house to have his servant reconstruct Namur and its environs on what had been a bowling green.

More on warts

A study on warts by D M Ewin raises further questions. Hypnotherapy for warts (verruca vulgaris): 41 consecutive cases with 33 cures, Am J Clin Hypn. 1992 Jul;35(1):1-10. Tulane Medical School, New Orleans, LA.

Published, controlled studies of the use of hypnosis to cure warts are confined to using direct suggestion in hypnosis (DSIH), with cure rates of 27% to 55%. Prepubertal children respond to DSIH almost without exception, but adults often do not. Clinically, many adults who fail to respond to DSIH will heal with individual hypnoanalytic techniques that cannot be tested against controls. By using hypnoanalysis on those who failed to respond to DSIH, 33 of 41 (80%) consecutive patients were cured, two were lost to follow-up, and six did not respond to treatment. Self-hypnosis was not used. Several illustrative cases are presented.

What distinguishes prepubertal children from adults?

Perhaps the biggest question, however, is why a little more of the billions spent on medical research isn't devoted to the mechanisms underlying this phenomenon. Tests of the phenomenon itself go back decades. Just to give one covered by Medline, a database of medical papers which begins in the mid-1950s, and discussed in our book: A H Sinclair-Gieben and D Chalmers, Evaluation of treatment of warts by hypnosis, Lancet, 1959 Oct 3;2:480-2.

The study actually involved 14 patients with multiple warts. Under hypnosis it was suggested to the patients that the side of their body the worse for warts would be cleared. Five were excluded as not adequately hypnotised since they failed the post-hypnotic suggestion that they would open the door when the clinician blew his nose; no change in their wart load was observed. The other nine patients were assessed over the next 5 -13 weeks. On the relevant side only, seven were totally cured and two, apart from one large fading wart, virtually cured: the other (control) side was unchanged in eight patients and cured in only one. If immune system activation alone was responsible for the warts regressing, it's difficult to explain the selective nature of the observed response.

This description of the paper, anecdotes, and physiological hypotheses come from a fascinating entry in this edition of Canberra Skeptics Argos. See section 6, Charming warts − not just hocus-pocus?

Skin complaints

Wart removal, with its long history of bizarre cures, has been the target of considerable interest from psychosomatic researchers, requiring as it does the occurrence of a change in the patient's resistance to a virus. While warts resist all manner of treatments, hypnosis has long been observed to be effective:

Noll RB., Hypnotherapy of a child with warts, J Dev Behav Pediatr. 1988 Apr;9(2):89-91.

Spanos NP, Stenstrom RJ, Johnston JC, Hypnosis, placebo, and suggestion in the treatment of warts, Psychosom Med. 1988 May-Jun;50(3): 245-60.

Spanos NP, Williams V, Gwynn MI., Effects of hypnotic, placebo, and salicylic acid treatments on wart regression, Psychosom Med. 1990 Jan-Feb;52(1): 109-14.

Phoenix SL., Psychotherapeutic intervention for numerous and large viral warts with adjunctive hypnosis: a case study, Am J Clin Hypn. 2007 Jan;49(3): 211-8.

But it's not just warts which are amenable to this kind of treatment. Skin complaints in general provide a fertile ground for psychological interventions. University of South Florida's professor of Medicine Philip D. Shenefelt concludes in Hypnosis in Dermatology, Arch Dermatol. 2000;136:393-399, that

A wide spectrum of dermatologic disorders may be improved or cured using hypnosis as an alternative or complementary therapy, including acne excoriée, alopecia areata, atopic dermatitis, congenital ichthyosiform erythroderma, dyshidrotic dermatitis, erythromelalgia, furuncles, glossodynia, herpes simplex, hyperhidrosis, ichthyosis vulgaris, lichen planus, neurodermatitis, nummular dermatitis, postherpetic neuralgia, pruritus, psoriasis, rosacea, trichotillomania, urticaria, verruca vulgaris, and vitiligo.

The question then arises as to whether there is something special about the skin, or whether changes there are simply more noticeable. That there's something peculiarly visual about skin complaints can be seen by turning to the relevant section of a medical textbook where one is often greeted by a plethora of florid pictures.

Shenefelt opts for the former explanation with a developmental physiological argument in Complementary psychocutaneous therapies in dermatology, Dermatol Clin. 2005 Oct;23(4): 723-34

The skin and the nervous system develop side by side in the fetus and remain intimately interconnected and interactive throughout life. Because of the skin-nervous system interactions, there is a significant psychosomatic or behavioral component to many dermatologic conditions. This permits complementary nonpharmacologic psychotherapeutic interventions, such as acupuncture, aromatherapy, biofeedback, cognitive-behavioral therapy, hypnosis, placebo, and suggestion, to have positive impacts on many dermatologic diseases.

This account is compatible with the skin being privileged as the site of others' touch and gaze. We report a case in our book where it is precisely the visibility of the skin that's at stake. A woman's belief that she caused her son's death leads to a series of disorders, shuffled about by her hypnotherapist, including a number of skin complaints, which involve both a punishment and a need to be seen to be punished.

The Nocebo effect

Over the past few posts I've been talking about the Placebo effect and the Roseto effect. A comment to an earlier post points to a relationship between them. As we discuss in our book, these effects occur in forms of social structure organised by the belief in a benevolent power which transcends the individual participants of the social engagement and which recognises their relative positions.

It's also worth considering the negative versions of the two effects. The first of these, the negative Placebo effect, has a name - the Nocebo effect. Just as, under certain conditions, the taking of what is considered a pharmacologically inert substance can produce beneficial effects in the body (reduction of gum swelling after surgery, increase in breathing capacity in asthmatics, etc.), so harmful effects can be produced.

Now, there's no name for the negative version of the Roseto effect, but it is clear that the disintegration of the social fabric in an individualistic consumer society is not conducive to good health. On the other hand, perhaps this is not the best way to formulate a societal parallel to the Nocebo effect. If Placebo and Nocebo effects take place in structured situations, to parallel the Nocebo effect we should look to tight-knit societal relationships capable of producing negative effects.

We do not have to look far to the colourfully named 'Voodoo deaths' studied by Walter Cannon. In his 1942 paper "Voodoo Death', which appeared in the American Anthropologist, Cannon wrote of the victim of a hex:

He stands aghast, with his eyes staring at the treacherous pointer, with his hands lifted as though to ward off the lethal medium, which he imagines is pouring into his body. His cheeks blanch and his eyes become glassy and the expression on his face becomes horribly distorted.

Perhaps we can see here one of the reasons Enlightenment thinkers wanted us to leave behind our superstition-laden traditional societal structures. But instead of a call to work these structures into a benevolent form, governed by a common good, we find encouraged something close to today's individualism:

It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own interest. We address ourselves, not to their humanity but to their self-love, and never talk to them of our own necessities but of their advantages. The Wealth of Nations

In the place of the Deity, Adam Smith invoked the Invisible Hand. While on the face of it this Invisible Hand is not malevolent, how many actions undertaken in its name have dissolved our social bonds?

What's the point?

Another review, this time in the Financial Times. Caroline Davies seems to be genuinely interested in the book's ideas, but shows some frustration that the pay-off isn't clear.

But perhaps the most worrying issue that the book does not resolve is how patients actually benefit from having the mind-body roots of their illness exposed. The practical difference these intellectual and psychological breakthroughs could make to the progress of an individual illness is never fully explained.

Perhaps it's as well that she's not in charge of astronomy funding, if intellectual curiosity alone does not suffice. But in the case of health provision, our concerns, as potential patients and tax payers, about waiting times and spiralling budgets make this impatience for practical consequences understandable.

For large number of patients the 'complaint' with which they address their doctor is just that, a complaint about their lives. Treating it as such should lead to a faster resolution of their problems and avoid unnecessary interventions. This seems to be better addressed in Germany, where Michael Balint made a much more pronounced iompact than in the UK.

But in our book we wanted to consider all forms of illness, including chronic diseases such as heart disease and diabetes. What would be fascinating would be to push on with treatments for such conditions, integrating orthodox measures with mind-body considerations. In view of the much poorer prognosis for depressed patients, joint interventions for their mental condition and their chronic condition, which have shown promising effects in many studies, should be enormously expanded.

Ultimately mind-body considerations point to more radical measures at the societal level. But here we face a condundrum - how to reproduce the Roseto effect?

The Roseto effect

This term refers to the Pennsylvanian town of Roseto, populated by Italian immigrants. As you can read here, when charted in the 1960s the inhabitants of the town scarcely suffered from any heart attacks before the age of 65, and after this age at only half the national average. And this despite usual levels of smoking, a not particularly healthy diet, and most men being employed as manual labourers.

We discuss the Roseto study and other similar studies, such as those on Japanese immigrants who remained healthy so long as they kept to their traditional modes of life, on pages 155-161 of the book. What can be done to recapture those healthy aspects of a society in which people "radiated a kind of joyous team spirit as they celebrated religious festivals and family landmarks" and where "any display of wealth was taboo"?

Placebo quandary

In Daniel E Moerman's Cultural variations in the placebo effect: ulcers, anxiety, and blood pressure, Medical Anthropology Quarterly 2000;14: 51-72, (summary is publicly accessible here), you can read about the opposition to the use of placebos made in some quarters. What case can those opposed make? Explicitly it boils down largely to the claims (1) that placebos don't work, (2) that their use is a deception and hence unethical.

There's a vast body of research which suggests that (1) is incorrect. But this still leaves us with the quandary (2), as this passage from Grant Gillett's excellent Bioethics in the Clinic: Hippocratic Reflections (John Hopkins 2004) suggests:

I was recently consulted about a patient who had a long-standing and refactory clinical depression. She had tried most of the available antidepressants but had not really had any good relief for her depression until she had been enrolled in a trial of a new drug. Her improvement since starting the new treatment had been dramatic and sustained, much to the relief of her clinical caregivers. She had, however, been in a placebo group in the trial. I was asked what her treating clinicians should tell her.

We may presume that the patient was aware that the drug she was receiving might have been a placebo.

It seems likely that for some practitioners the problem really lies in placebos threatening their sense that they are people of science. A nobler concern would be that they are withholding information necessary to establish a trusting relationship with their patient. Elsewhere in Gillett's book we read a quotation from an essay by Ron Carson, which expresses such an ideal form of partnership:

The hyphenated space in the doctor-patient relationship is a liminal place of ethical encounter, alternating voices and actions - back and forth, address and response - seeking mutually satisfactory meaning by means of which an illness that has threatened to fray or sever the storyline of a life can be woven into the fabric of that life. The hyphen points to the prospect of overcoming silence with meaningful conversation. (p. 77)

Even if this is accepted as the aim of one's practice, there could still be a place for placebos within the process of arriving at such a point.

Causal complexity

Another piece of research pointing to the link between depression and a major illness. This time it's about the joint effect of depression and Type 2 diabetes on heart disease. Each factor is known to increase the risk of heart disease, but they act more potently together. Of course, extracting a causal picture from all this is very difficult. Depression is known to increase insulin resistance. One might propose, then, that there's a particular danger for the heart from depression-induced diabetes.

But one can think up any number of ways in which the interaction may occur. A common style of hypothesising is exemplified by the researcher Anastasia Georgiades herself:

"Patients with type 2 diabetes typically have an extensive self-care regimen involving special diet, medications, exercise and numerous appointments with their doctor," she said. "It may be that such patients who are depressed might not be as motivated to carry out all these activities, thereby putting them at higher risk."

But even if you could show that the more depressed take less care of themselves, after what I discussed in the last post, how do we know that an effect on the heart isn't also produced by the depressed patient's lack of faith in medicine, or reduced will to live? We can't exclude the need to use this kind of language.

Then there's the matter of how placebos can effect depression. Here is a report of research which suggests brain-scanning can tell the difference between placebo-induced and medication-induced relief. Andrew Leuchter of UCLA remarks:

"Medications are effective, but there may be other ways to help people get better. If we can identify what some of the mechanisms are that help people get better with placebo, we may be able to make treatments more effective."

Interestingly he uses language referring to the subjectivity of the patients:

"...they made a decision to come in for treatment," he said. "They were prepared to get well. They came in, they actually got engaged with somebody. They started talking with staff, with nurses, with the physician. They got a lot of extra attention."

If the global warming debate involves extremely intricate causal mechanisms, there's no reason to expect any less intricacy in the case of human health. And perhaps with the necessity to talk about patients' subjectivity, this latter case is in a sense more difficult.

The Placebo Effect

As you might expect, for the book Darian and I were very interested in what is termed the 'Placebo effect'. Fascinating changes to bodily symptoms can be produced by 'inert' medication or 'fake' surgery in ways which depend upon its presentation, for example, a pill's colour, but perhaps most importantly upon a physician's belief in the treatment's efficacy.

An excellent book on this topic is medical anthropologist Daniel E. Moerman's Meaning, Medicine and the 'Placebo Effect', Cambridge University Press, 2002. Online you can gain a good idea of the range of this book from an informative review in the London Review of Books, and from an article Moerman co-authored with Wayne B. Jonas, 'Deconstructing the Placebo Effect and Finding the Meaning Response':

Abstract: We provide a new perspective with which to understand what for a half century has been known as the “placebo effect.” We argue that, as currently used, the concept includes much that has nothing to do with placebos, confusing the most interesting and important aspects of the phenomenon. We propose a new way to
understand those aspects of medical care, plus a broad range of additional human experiences, by focusing on the idea of “meaning,” to which people, when they are sick, often respond. We review several of the many areas in medicine in which meaning affects illness or healing and introduce the idea of the “meaning response.” We suggest that use of this formulation, rather than the fixation on inert placebos, will probably lead to far greater insight into how treatment works and perhaps to real improvements in human well-being. Annals of Internal Medicine 2002;136:471-476.

You can read there about differences in placebo effects across countries, e.g., Germans are more responsive to ulcer placebos than fellow Europeans, but less so with blood-pressure drugs. Also Chinese Americans dying from lymphatic cancer who were born in an 'Earth year', according to their calendar, died on average nearly 4 years earlier than those dying from the same condition but born in other years.

Giving psychoanalysis its due

You can find an interview with Darian in April's edition of Psychologies.

And a review by Christopher Tayler appeared in last Sunday's Telegraph. It's curious how people assume in a jointly authored book that they can tell who did what. I'm taken to have "dug out lots of interesting stuff from the medical literature on psychosomatic illnesses, while Leader, an analyst, provides anecdotal case histories". How does someone think they can guess correctly about this matter?

To make the point once again, we insist on using 'psychosomatic' to describe an approach to medicine rather than a type of illness. We document the extensive research which indicates the mind's involvement in a wide range of conditions, from allergic reactions to heart disease. If there was one aspect of the book to which I contributed predominantly it concerns what physiologists have discovered of how nervous, endocrine, and immune systems intercommunicate, and of how these systems may impact on the blood vessels and on tumours. From the reviews I've seen you'd hardly guess that the book contained a murmur about T-cells or the endothelium.

If I'm allowed to return the guess, perhaps this imagined division of labour helps Tayler to recognise psychosomatic medicine without acknowledging its debt to psychoanalysis. At the very least one can say that he does not look favourably upon the latter.

...the authors don't acknowledge the fact that psychoanalysis has a poor track record when it comes to distinguishing psychosomatic complaints from ones with less mysterious causes.

Again that use of 'psychosomatic' we wish to avoid. But what is this 'fact' alluded to? Psychoanalysis is a broad theory. Certainly excessive claims have been made by individuals in the past, but we're very careful to distance ourselves from the non-Freudian idea that all medical conditions are a form of bodily speech - the unconscious speaking through the body - a position which did find its voice in the 1920s and 30s.

The theorists we turned to were physician-analysts such as George Engel, Michael Balint and Jacques Lacan, and more recent Parisian analysts, such as Joyce McDougall and Rosine Debray.

The authors do address 'the failure of classical old-fashioned psychoanalysis as a clinical treatment', but they get round the problem by recommending the less classical methods of Jacques Lacan.

I don't see where we even do that. But whatever one's attitude towards psychoanalysis, surely we should at least give some credit to these people, and to the way psychoanalysis framed certain questions for them. In the middle of the last century we see Lacan considering whether the structure of society plays a role in the incidence of heart disease, a thesis later research confirmed. Meanwhile, Michael Balint was speculating about the mind's involvement in chronic illnesses by means of the immune system's inflammatory response. This was a wonderfully accurate prediction.

Even someone who is distrustful of psychoanalysis should acknowledge that its capacity to look to the patient's story beyond simplistic personality profiling kept the psychosomatic flame alive in the third quarter of the twentieth century. Which other forms of psychology can boast as much?

Thriving and flourishing

Anyone interested in the mind’s involvement in health confronts the difficulty of making two vocabularies connect to each other. What is at stake is a relationship between thriving as a mammalian body and flourishing as a human being. While it is less controversial to think that a failure to thrive bodily may impact on one’s ability to flourish personally, our sense of this impact has changed as it has become less determined through the past century that a physical handicap will necessary force you to limit your life plans. Where 4000 athletes participated in the 2004 Paralympic Games in Athens, it would have been unthinkable in the Athens of 1896.

But we are interested in an impact which runs the other way, a failure to flourish bringing about a failure to thrive. Now, anyone writing about such phenomena must have a conception of what it is for a human to flourish, and this necessarily relates to their political and ethical beliefs. For instance, we might claim that we cannot flourish if made to work an 80 hour week as insufficient leisure time would remain to allow us to live fully as people. But the drive to make the psychological end of the matter ‘scientific’, which includes a movement to free vocabulary from value judgements about what the Greeks called ‘eudaimonia’, the good life, attempts to avoid this difficulty. It must fail. Generally it achieves its conjuring trick by implicit reliance on the everyday ethics and politics of the kind of late capitalist, Western liberal democracy in which it takes place.

We are used to our qualities being scored in various ways - our credit rating, our attractiveness to the immigration services of another country, our research achievements for Higher Education’s Research Assessment Exercise. Unsurprisingly, then, a large part of the psychosomatic literature has looked to form a total of the number and severity of 'life events' we have faced: so many points for loss of spouse, so many for caring for dependent spouse, for loss of job, for moving house, etc. Implicitly a view is taken here that adverse events have an objectively quality in terms of their impact on our lives. We find for example that "caring for a dependent partner ages our immune system". But is this effect really independent of the ethical-political environment in which such an event occurs?

The BBC have recently broadcast Jane Eyre in 4 one hour episodes. This is not nearly enough to do justice to the book, of course. What is so clear here, and in many other cases of adaptations, is how time and again directors fail to let the past judge the present. Remaking ‘Pride and Prejudice’, we lose the Shaftsburyesque moral philosophy of Jane Austen, and instead project our contemporary 'girl power' back into the early nineteenth century. In the case of Jane Eyre, we scarcely touch upon the variety of brands of religious belief and practice prevalent in nineteenth centruy England. Only glimpses are offered of the missionary zeal of St. John Rivers, the mysticism Helen Burns imparts to the young Jane, or indeed much of Jane's own beliefs. We are not told that Jane sets herself the task of drawing herself and how she imagines Blanche Ingram to look as an exercise in correcting a moral failing she has located within herself.

To return to the topic of the adverse life events, consider this passage, which beautifully expresses a conception of the good life:

Mr. Rochester continued blind the first two years of our union: perhaps it was that circumstance that drew us so very near-that knit us so very close! for I was then his vision, as I am still his right hand. Literally, I was (what he often called me) the apple of his eye. He saw nature-he saw books through me; and never did I weary of gazing for his behalf, and of putting into words the effect of field, tree, town, river, cloud, sunbeam-of the landscape before us; of the weather round us-and impressing by sound on his ear what light could no longer stamp on his eye. Never did I weary of reading to him; never did I weary of conducting him where he wished to go: of doing for him what he wished to be done. And there was a pleasure in my services, most full, most exquisite, even though sad - because he claimed these services without painful shame or damping humiliation. He loved me so truly, that he knew no reluctance in profiting by my attendance: he felt that I loved him so fondly, that to yield that attendance was to indulge my sweetest wishes.

What a gloriously intricate web of feelings expressed at the end. If we could aspire to these feelings in our relations to our dependents, how differently then might the ‘life event’ of caring impact on our health? For a contemporary philosophical discussion of an ethics which acknowledges our dependency on others and their dependency on us, I thoroughly recommend Alasdair MacIntyre's ‘Rational Dependent Animals’, where it is explained how, rather than seeing the provision of care for others as a burden, we should find that our good resides in it.

Type 2 Diabetes

The increase in the incidence of diabetes has been described as an epidemic. In 2004, 5% of Americans reported themselves as diabetic.

The vast majority of these will have Type 2 diabetes. Unlike in Type 1 diabetes where insulin producing cells are destroyed by the body's own immune system, in Type 2 there is insulin available. It's just that it can't do its job properly of storing glucose in fat cells, leaving potentially dangerously high levels of glucose in the blood.

Israeli scientists prospectively studying subjects who suffered from 'burnout', found a 1.84-fold increased risk of type 2 diabetes in apparently healthy individuals, after controlling for the usual confounding variables. When they also controlled for blood pressure in a subsample, they found the risk factor to be greater than 4.

As ever, it's the personal part of the assessment that causes the problem for the scientist. How do you convince the scientific community that you've objectively measured psychological variables? With a measure, of course.

Burnout was assessed by the Shirom-Melamed Burnout Measure with its three subscales: emotional exhaustion, physical fatigue, and cognitive weariness.

Someone could do us a great service by conducting a survey of the psychological measures out there. How long do they last in use? Do psychologists other than the originators use them?

Again, I'm left wanting to know more about those poor souls who suffered burnout. A similar study carried out on British civil servants found an inverse correlation between rank and diabetes incidence whch could not be wholly explained by health behaviours and other risk factors. Many other illnesses followed this pattern. The lower your rank, the more likely you will die early from a host of conditions.

Something I suspect may be key to this phenomenon is what is called the effort-reward imbalance. (Take a look at how this is measured.) I'd like to hear subjects describe in their own language what they think about their jobs and careers.

When symptoms persist

Irritable bowel syndrome is a prevalent condition. Some estimates put its incidence in the UK as high as 13 per cent for women and 5 per cent for men. Around 1 in 10 cases occur after a gut infection.

Now, the BBC reports the following research:

Perfectionists are more prone to developing irritable bowel syndrome (IBS) after an infection, a study has suggested. University of Southampton researchers asked 620 people with gastroenteritis about stress and their illness. Those who pushed themselves or were particularly anxious about symptoms were more likely to develop IBS. Experts said the study, published in Gut, may explain why only some people develop IBS after a gut infection.

The conclusions from the paper are as follows:

Results suggest that patients with high stress and anxiety levels are more prone to develop IBS after a bout of gastroenteritis. Additional risk factors include a tendency to interpret illness in a pessimistic fashion and to respond to symptoms in an all-or-nothing manner

Something I find curious about this report is that when the BBC invites Professor Robin Spiller, an IBS expert from University Hospitals Nottingham and the editor of Gut, to comment, he says

"There is probably a complicated mechanism at work here." He said there were two potential explanations. "It might be that stress and anxiety affects the immune system. But it could also be that if you don't rest, it might do you more harm."

But it's not as though this is the first piece of research on the subject. My home town of Ilkley in West Yorkshire has a second author of a book on psychosomatic medicine. I met Nick Read, a consultant gasteroenterologist and a psychoanalytic psychotherapist, as we ran a session together at the Ilkley Literature Festival. In his book, Sick and Tired: Healing the illnesses doctors cannot cure (Phoenix 2005, page 121), Nick reports on research carried out by a colleague, Dr. Kok-Ann Gwee, which studied over 100 people admitted to hospital with acute gasteroenteritis.

Those in whom the symptoms persisted had suffered more anxiety or depression at the time of the acute illness and had experienced more traumatic life events during the six months prior to the gasteroenteritis.

Further studies showed this to be the case for other kinds of infection.

Emotional upset at the time of the acute illness predicted the persistence of the original symptoms. Or to put it a different way, it appeared as if the symptoms of the acute infection had been 'recruited' to express an unresolved emotional problem. (page 122)

So this would seem to rule out the 'lack of rest' theory.

I should add that Nick's book can be recommended for other reasons. Besides reporting on such large sample research, he also includes many vignettes of his patients, weaving their illnesses with their life stories.

Putting two and two together

More than 1.7 million people in the UK will have dementia by 2051, costing billions of pounds each year, experts have forecast. (BBC)

People who are lonely are twice as likely to develop Alzheimer's disease, a large US study has suggested. (Earlier post)

Added: To help with the sum, note that

One in 20 people over 65 and one in five people over 80 has a form of dementia. Around two thirds of those affected have Alzheimer's disease.