Thursday, 8 February 2007

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.


Andy said...

How about a combination of statistical machinery and a wee chat? Give people a load of tests, n > 100, use structural equation modelling, or whatever, and then extract a few cases to tell their story as well?

Are you aware of anyone doing this kind of thing?

David Corfield said...

Right. Ideally a combination of physiology, statistical sampling, and detailed case studies is what's wanted. For me something like the balance Jared Diamond strikes in 'Collapse', a study of the health of societies and whether they meet with ecological disaster, is right.

One very large obstacle that stands in the way of this, however, is disagreement as to the choice of psychological variables for the statistical study. Can psychology escape from value-laden categories? Is it inevitably to be entangled with ethical/political theory? It's certainly not original to point to the ethical aspect of psychoanalysis.

I think one motivation for psychologists resorting to personality tests is that they imagine that they can escape value-ladenness and so remain 'scientific'. But then if they're using these variables there's little point in the lengthy case study. How to extract universal variables from the richer, almost novelesque, language of the case study?

But then there's very little agreement as to personality variables anyway.