Monday, 30 April 2007

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.

Wednesday, 25 April 2007

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.

Thursday, 19 April 2007

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.
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?

Monday, 16 April 2007

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.

Friday, 13 April 2007

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.

Monday, 9 April 2007

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?

Friday, 6 April 2007

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: 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.

Wednesday, 4 April 2007

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.

Monday, 2 April 2007

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.