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.