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.

Unnecessary treatment

First some media coverage. Darian appeared on Radio 4's Start The Week. If you just want to hear about our book, it is discussed towards the end of the programme.

Darian is also mentioned in passing in Rowan Pelling's article in The Independent, My part in the NHS funding crisis. This article was written in response to a television programme, Hypochondriacs: I Told You I Was Ill Last Monday.

While the Channel 4 programme estimated that one in four of GPs' patients may be hypochondriacs, other research suggests the proportion could be as high as 50 per cent. Clearly, modern medicine can't cope with an epidemic of this scale.

I have similar worries about the use of the word 'hypochondriac' here as I do about the use of the word psychosomatic. We should resist the idea that there's a sharp distinction between the true organic illness and the false all-in-the-mind one.

But, that understood, the article raises the important question of how much of the treatment provided by the health service is unnecessary. Now, of course, 'unnecessary treatment' doesn't include every test which proves negative. It's clearly important to rule out possible conditions.

In our book we mention government research in the US, which reckons that over 7 million surgeries a year are unnecessary. It would be interesting to carry out a survey of health professionals to assess how much medication and how many medical tests they rate as unnecessary, and the reasons why they still persist with these treatments.

A book co-authored by Michael Balint in 1970, Treatment or diagnosis: a study of repeat prescriptions in general practice. London. Tavistock publications, gives useful insight into arrangements doctors and patients can enter into, without the doctor necessarily believing a medication to be medically efficacious.

Living a contradiction

Another review in today's Guardian, this one by Hilary Mantel. I'm very pleased that she notes "This is not a doctor-bashing book". I also like the way our book is reviewed together with an account by the Canadian novellist Jan Lars Jensen of an episode of mental illness he suffered.

As he feels his way back to reality, he takes charge of his own narrative again, a walking illustration of Leader and Corfield's thesis that healing occurs most readily when a patient can patch together his own story.

This points to perhaps the major target of our criticism in the book - a simplistic psychology of personality traits.

As I've note in an earlier post, the problem is not that psychosomatic research has disappeared. Far from it. An enormous number of papers are printed each year, the physiological ones providing great insight into the mechanisms underlying the mind-body relation. What we object to are the psychological models employed in the search for correlations between characteristics of people and types of ill health. These models see a human in terms of a list of traits. Each of us is captured by a series of numbers: how lonely, how time-anxious, how compliant to other's wishes, how many severe life events we've experienced, how emotionally close we were to our parents, how loving a relationship we are in, how able we are to name our emotional state, and so on. Having measured a few of these traits in a sample of subjects, and then perhaps made them undergo the 'same' experience (hug partner, give a speech, perform mental arithmetic in public,...), a physical measurement is then made (ability of blood vessels to dilate, activity of natural killer immune cells, cortisol levels,...) and correlations sought.

So what's wrong with this? Well, we believe that viewing people as lists of traits is wrong-headed. To put things as succintly as possible, what is required is that we attend to the contradictions in people's lives. Against the idea of a constant trait, we may find that a person's incompatible identifications make them behave differently according to the situation they are in.What they display in the experimental situation may be telling the scientists about only one small facet of their subject. But this idea of a tension or conflict goes deeper, and only emerges over a lengthy engagement with a person.

Let me illustrate one of these tensions by returning to Freud. In 'On the Universal Tendency to Debasement in the Sphere of Love', he discusses the problem caused by the impossibility for many men of having the "affectionate" and the "sensual" currents directed towards the same person. They cannot then both love and desire the same woman.

But we can go back further to Plato for a representation of the problem of competing demands. In The Republic Book VIII, Socrates is explaining how a city state descends fom the perfect form to a lesser one. He does so in parallel with a description of the formation of less than perfect individuals. Here is his explanation of the creation of a 'timocratic' citizen.

His origin is as follows: --He is often the young son of a grave father, who dwells in an ill-governed city, of which he declines the honours and offices, and will not go to law, or exert himself in any way, but is ready to waive his rights in order that he may escape trouble.

And how does the son come into being?

The character of the son begins to develop when he hears his mother complaining that her husband has no place in the government, of which the consequence is that she has no precedence among other women. Further, when she sees her husband not very eager about money, and instead of battling and railing in the law courts or assembly, taking whatever happens to him quietly; and when she observes that his thoughts always centre in himself, while he treats her with very considerable indifference, she is annoyed, and says to her son that his father is only half a man and far too easy-going: adding all the other complaints about her own ill-treatment which women are so fond of rehearsing.

Yes, said Adeimantus, they give us plenty of them, and their complaints are so like themselves.

And you know, I said, that the old servants also, who are supposed to be attached to the family, from time to time talk privately in the same strain to the son; and if they see any one who owes money to his father, or is wronging him in any way, and he falls to prosecute them, they tell the youth that when he grows up he must retaliate upon people of this sort, and be more of a man than his father. He has only to walk abroad and he hears and sees the same sort of thing: those who do their own business in the city are called simpletons, and held in no esteem, while the busy-bodies are honoured and applauded. The result is that the young man, hearing and seeing all these thing --hearing too, the words of his father, and having a nearer view of his way of life, and making comparisons of him and others --is drawn opposite ways: while his father is watering and nourishing the rational principle in his soul, the others are encouraging the passionate and appetitive; and he being not originally of a bad nature, but having kept bad company, is at last brought by their joint influence to a middle point, and gives up the kingdom which is within him to the middle principle of contentiousness and passion, and becomes arrogant and ambitious.

The exploration of lived contradictions is what takes place in psychoanalysis.

Guardian interview

An interview with Darian in today's Guardian, which is largely friendly, but which contains two major errors. We have sent the following letter to the Guardian.

Dear Guardian,
We were very pleased to read the piece in Friday's Guardian about our book 'Why do people get ill?, yet wanted to correct two important errors in it. The claim ascribed to us that "Illness - even cancer - is the body's way of communicating..." is exactly what the book argues against. A whole chapter spells this out clearly, as does a does a chapter devoted specifically to cancer. Our argument is actually that not all illnesses are attempts at communication. Believing this to be the case was one of the great problems with early psychosomatic research. The piece also quotes one of us as setting the beneficial outcome of psychoanalysis at 20 to 30 years, figures that are of course absurd and which were nowhere stated.
Sincerely
Darian leader and David Corfield

Aside from these, I found another comment of Stuart Jeffries a little odd. After mentioning a case of an artist being treated for the effects of teeth grinding (bruxism), Jeffries writes:

One of my problems with Leader's new book is that while it may be convincing to argue that grinding one's teeth has a psychological cause, can it be true that cancer and heart disease may have psychological factors in what Leader calls the "constellation of causes"?

Now the interview took place before the book came out, so possibly Jeffries hadn't had the chance to read an advance copy. But then why is talking about his "problems with Leader's new book"? On the other hand, if he had read it, why didn't he explain what he found implausible about the chapters on heart disease and cancer, and the supporting chapter on the immune system?

He ends by saying that Darian "may well be a voice out of time", in the sense that even if the message of our book is right, it is quite likely to be ignored by government and doctors. Well, we're hardly expecting an overnight transformation. And even if it is ignored, if right, then it ought to have been written. Finally, our audience is not restricted to the government and medical profession. We all have a responsibility to contribute to a healthier society. The person who bullies a workplace colleague may be contributing to more than mental anguish.

The smallpox 'argument'

Darian appeared on Radio 3's Night Waves yesterday evening. He was discussing the book with a sympathetic clinical geneticist and an antipathetic neurophysiologist. The latter brought up the case of smallpox again, in a very similar way to Theodore Dalrymple in his review mentioned four posts ago. I struggle to understand this argument but let me give it my best shot:

Premise: Psychotherapy can't cure smallpox
Premise: If there exists a disease which psychotherapy can't cure, no psychological factors are relevant to any disease.

Conclusion: No psychological factors are relevant to any disease.

Can that be it? How could they justify the second premise? Besides the curious jump from one disease to all diseases, they must hold something like:

Premise: If psychological factors are relevant to a disease, then psychotherapy should be able to cure it.

Now how far is this from expecting that after a lighted match has set off an explosion of gas, that blowing out the match will undo the effects of the explosion?

An only slightly less unreasonable smallpox argument would be:

Premise: No psychological factors are relevant to smallpox
Premise: If there exists a disease to which no psychosocial factors are relevant, no psychological factors are relevant to any disease.

Conclusion: No psychological factors are relevant to any disease.

Still a bad argument. We could show that all Cambodians are wholly evil, if we allowed 'If there exists a wholly evil Cambodian, then all Cambodians are wholly evil', and 'Pol Pot was wholly evil'.

But even here there would be some small scope for attack on the first premise. The work of Davidson on meditation and flu vaccine, I mentioned four posts ago, shows how an immune response is affected by mental state.

A note on HIV patients

The effect of the psychosocial environment on the course of HIV infection and the development of AIDS has been studied from the early days of its appearance in the West. As this memorial note describes, already in the 1970s George Solomon was investigating "the characteristics of long-term AIDS patients and the psychobiological mechanisms that contributed to their health and longevity". His book 'From Psyche to Soma and Back' is a fascinating account of this work, and of his whole research career.

Now we live in a time when anti-retroviral drugs have proved to be very effective, and one might be excused for thinking psychological factors are no longer of any import. So we were very interested to receive the following note.

A consultant working with HIV has observed the effects of psychological factors on the body over several years of his practice. When HIV/AIDS first appeared and medicine struggled to deal with the virus all the early patients died. Now it is quite rare for people to die and a high percentage of HIV+ patients consistently have undetectable viral load.

He has always tried to create good personal relationships with patients. This is partly inevitable due to the aspects of life examined in the course of treatment, such as sex, love, guilt and death; but it also seemed to help keep people in better health and more likely to stick to their drug regimens once the current, highly effective, combination therapies were developed.

A few years ago, he was absent from his post for some months; he noticed when he returned and checked results on patients' viral loads, that some of those whose levels had been undetectable for long periods of time had shown a significant increase. They went back to undetectable levels after he'd been back a couple of months.

The psychological relation to the doctor here seems to be having a direct effect on the body.

This condition is an excellent one to study as viral loads are measured regularly and frequently.

The meaning of 'psychosomatic'

From an article, 'Confessions of a Fraud and Failure', by Bryan Lask:

The term ‘psychosomatic’ has been much misused, most commonly to describe conditions for which an organic cause cannot be found and in which psychological factors are deemed to be important. Such an approach is not only narrow but inaccurate. The fact that an organic contribution cannot be found does not signify absence – molecular biology and genetics are providing remarkable new insights and it now seems likely that there is an organic contribution to all conditions. Similarly, there are no situations in which psychosocial elements are irrelevant, with the possibility of them operating as predisposing, precipitating and/or perpetuating factors. Psychosomatic medicine acknowledges the totality of a condition, the biological, the psychological and the social.

One of the earliest descriptions of this concept was provided by Richardson in 1945 in a fascinating book entitled Patients have Families. Physician turned psychiatrist he stated ‘the time is now ripe for a coordinated attack on the problems of family adjustment in relation to maintenance of health and the treatment of illness . . . the many opportunities for enhancing the value of medical treatment are now being lost through overlooking the importance of the family unit’. Way ahead of his time Richardson was an unacknowledged revolutionary. (p. 459)

The time is still ripe.

Lask's father, Aaron, was author of Asthma, Attitudes and Milieu (Tavistock: 1966).

The Benefits of Hugging

The BBC website carries the report that hugging has beneficial effects on the heart, especially in women. It's not clear from the report which paper they are drawing on, but one of the researchers mentioned, Karen Grewen, wrote a paper, 'Effects of Partner Support on Resting Oxytocin, Cortisol, Norepinephrine, and Blood Pressure Before and After Warm Partner Contact', in Psychosomatic Medicine 2005 Jul-Aug.

Subjects were 38 cohabiting couples (38 men, 38 women) aged 20 to 49 years. All underwent 10 minutes of resting baseline alone, 10 minutes of WC together with their partner, and 10 minutes of postcontact rest alone.

Don't you just love the acronyms of contemporary research. WC apparently stands for 'warm contact'.

The physiological mechanism appears to involve the hormone oxytocin, perhaps best known for its role in 'bonding' mother to child.

More press coverage

An article by Christina Patterson in The Independent. Reviews by Lisa Appignanesi in The Observer today, and David Shukman in The Mail and Hanif Kureishi and William Leith (p. 62 of magazine) in the Telegraph (Saturday 17 February). There's a feaure in March edition of Harpers and an interview with us in The New Scientist.

We're pleased that coverage has been so positive. But there have been two less favourable reactions. Darian featured on Sky News (Saturday 17) and was pitched against an irate doctor, who based on a perusal of the press release took us to be trying to dictate to GPs how to practise.

The Sunday Times carries a review of our book by Theodore Dalrymple. In a bizarre series of claims about our views, we hear that "the authors depict surgeons almost as necrophiliacs" and that we believe "that hypoglycaemic attacks are the consequence of diabetes rather than of the treatment of diabetes". For the latter claim I can only imagine he has misunderstood our discussion of a case study by Rosine Debray:

In another case, a diabetic man experienced a hypoglycaemic episode while speaking with a therapist. This dangerous deficiency of glucose in the bloodstream, which had often sent him into a diabetic coma in his past, had occurred while he was describing his son’s first communion. As he spoke, he became pale, trembling and confused. Reaching for the glucose he carried with him, he was unable to open the packet, fumbling and lacking the coordination necessary to handle it. (p. 67)

On weekends, the patient would spend all his time working flat out on restoring a country house. He would systematically neglect to modify his insulin dosage, although he knew full well that this would be necessary given the physical exertions he was subjecting himself to. The result was frequent hypoglycaemic episodes as well as diabetic comas, occurring almost always on weekends. (p. 274)

Type 1 diabetics have a balancing act to perform between providing their bodies with sufficient insulin to extract excess glucose from the blood, while ensuring that their food intake maintains sufficient levels. Hypoglycaemia may result from the insulin side of the balance tipping too far. As our first extract records, the treatment for this is to ingest glucose. This balancing act would become all the more difficult during an intense period of physical exertion. Perhaps we might have avoided misunderstanding by adding that the patient also neglected to control his food intake. But if Dalrymple is so keen to find fault, he's sure to find it.

His critique of our understanding of diabetes comes after this:

Having emphasised, indeed overemphasised, the role of psychology in the production of illness throughout the book, the authors ask whether it would not be better if the basic training of doctors were in literature and philosophy rather than in the natural sciences (David Corfield is a philosopher by training). The answer, I think, is a resounding no. While I would prefer my doctor to be cultured rather than a philistine, and to have a wide outlook, I would, even more, like him to have some grasp of physiology and biochemistry...

It would seem strange in a book which dwells probably much longer than most editors might have wished on the details of the immune system, the heart and the formation of tumours, that its authors would be advocating that doctors not be trained in physiology and biochemistry. And of course we don't. What is at issue is the balance to be struck in doctors' training. In view of the research reported in our book, and don't forget nearly all was carried out by medical professionals, we suggested that more time be devoted to improving trainee doctors' understanding of humans as people, especially those intending to become GPs. At present this allocation is vanishly small. This could be organised through a literature course, or perhaps better, through one which takes in books written by doctors such as Michael Balint's The Doctor, The Patient and His Illness and James Lynch's Broken Heart: Medical Consequences of Loneliness.

In a final blast, we read that

The authors do not appear to understand the limitations even of their strongest evidence. No doubt people often contracted smallpox at the lowest ebb of their lives rather than at the peaks of their existence; nevertheless, smallpox was eradicated by immunisation, not by empathy or the talking treatment.

A curious passage. Having seemingly agreed with us at the beginning of the review about the complexity of illness, we stand accused of a psychological reductionism nowhere maintained in the book itself. Indeed it seems to be Dalrymple who relapses to a simplistic psychological/medical dichotomy. Immunisation is a fascinating topic. Although deaths from many disease were declining through public health measures introduced before vaccinations were designed, clearly we have them to thank for the eradication of smallpox. But immunisation is not a simple mechanical process. Did you realise how your reaction to a vaccine can depend on the time of day it is given to you (page 215)? Or that your response to a flu vaccine can be increased by sessions of 'mindful meditation' (page 285).

Doctors who have given us their private opinions have been overwhelmingly positive. I fear, however, that what we hear and read in the media will be counterattacks from those who have taken us to be aggressively critical of the medical profession. Is dialogue impossible nowadays?

Our Children's Health

Two studies reported in the media today. First, 1400 babies born in the period 1937-1939 were tracked to see if being breastfed correlated with long-term health and social mobility. And indeed it does. But why? Listening to a researcher being interviewed on the Today programme this morning, I thought we had another case of overlooking psychological variables. He described how, unlike today where better educated woman are more likely to breastfeed, in the past there was no correlation with class. I took it then that his team were limiting themselves to nutritional explanations. So, I was pleasantly surprised to read:

The question is whether that's an effect of the breastfeeding - something to do with the biological process which has an effect on brain development, or about the activity itself - such as improved bonding with mother, or that people who were breastfed were raised in a better social environment.

Good. Let's hope they look into maternal depression too. It is extraordinary, though, how psychological factors do get overlooked. In our book we discuss research findings which detected a link between childhood leukaemia and sleeping with a light on at night. Possible explanations in terms of effect of light on hormones were proffered, but no interest was shown in the question of why the child had the light on in the first place.

The second study is Unicef's report placing the UK at the bottom of a league of 21 industrialised nations in terms of child welfare. Much of the discussion concentrated on childhood poverty and the government's record on lifting children out of it. But I think what concerns me most is the finding that "Britain had the lowest proportion of children who found their friends kind and helpful - 40%, compared to 80% in Switzerland", coupled with the findings from a Institute for Public Policy Research study that:

In England, 45% of 15-year-old boys spend most evenings out with their friends, and in Scotland the figure is 59%. In France just 17% of boys spend their time in the same way. On the other hand, European teenagers tend to sit down for meals with their parents far more often. Some 93% of Italian teenagers eat regularly with their families; in the UK just 64% of 15-year-olds do the same.

Bearing in mind the Roseto effect, we should fear for our nation's future health.

Of course, we shouldn't forget the point, made frequently in our book, that people's responses to questionnaires may tell us more about the way people wish to appear to those running them than anything else. Surveys have suggested that up to 54% of people would donate a kidney to a stranger who needed a transplant, but I somehow doubt that this would translate into actual donation. So, perhaps our teenagers just like to appear bolshie to interviewers.

Press coverage

The February 10 edition of The Times ran an article on our book, as did the February 12 edition of the Yorkshire Post.

Psychosomatic Medicine

The journal Psychosomatic Medicine has been operating now for almost 70 years. In its early days, under the influence of psychoanalysis, there was plenty of room for individual case studies. For example, here in 1939, Phyllis Greenacre described a case of someone addicted to surgery. Here in the same year, we read about a case of a young patient with a chronic skin disorder.

A typical paper today, on the other hand, 'measures' a 'psychological variable' in a sample of people, and then looks to find a correlation with some measure of illness. For example, in Positive Emotional Style Predicts Resistance to Illness After Experimental Exposure to Rhinovirus or Influenza A Virus:

One hundred ninety-three healthy volunteers ages 21 to 55 years were assessed for a PES [positive emotional style] characterized by being happy, lively, and calm; a negative emotional style (NES) characterized by being anxious, hostile, and depressed; other cognitive and social dispositions; and self-reported health. Subsequently, they were exposed by nasal drops to a rhinovirus or influenza virus and monitored in quarantine for objective signs of illness and self-reported symptoms.

For both viruses, increased PES was associated with lower risk of developing an upper respiratory illness as defined by objective criteria (adjusted odds ratio comparing lowest with highest tertile = 2.9) and with reporting fewer symptoms than expected from concurrent objective markers of illness.

I'm certainly not suggesting that statistical approaches should be avoided, but it's hard to escape the impression that something important is missing. If these people moved over to literary criticism would they try to average over Jane Austen heroines?

Despite researchers consistently making statistical findings like this, with endless minor variations, little filters through to medical practice. But then how could practitioners use them? How could they instill a 'positive emotional style'? Whether a return to a narrative approach would resonate more strongly with practitioners is perhaps dubious, but at least, if it did, it should open them to the idea of listening to the patient's story.

Loneliness and Alzheimer's

Reported by the BBC:

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

Professor Wilson, professor of neuropsychology at Rush University Medical Centre said: "There are two ideas that we should take away, number one is it suggests that loneliness really is a risk factor and secondly in trying to understand that association we need to look outside the typical neuropathology."

He said the results ruled out the possibility that loneliness is a reaction to dementia...

"We need to be aware that loneliness doesn't just have an emotional impact but a physical impact," he said...

Rebecca Wood chief executive of the Alzheimer's Research Trust said: "This is an impressive study. It follows a large group of people for a significant period of time and comes up with startling findings that back up earlier studies examining social interaction and Alzheimer's risk.

"What I find particularly interesting about this study is the fact that it is an individual's perception of being lonely rather than their actual degree of social isolation that seems to correlate most closely with their Alzheimer's risk."

Given the track record of turning 'risk factors' into medical conditions, how long before the 'perception of being lonely' gets a medical tag?