The New Black

Apparently, 44 is the age at which we're most vulnerable to depression. That gives me 6 months to put up the defences. Something I might do is to (re-)read Darian's book - The New Black: Mourning, Melancholia and Depression - which appears on Thursday.

The publisher's (Hamish Hamilton) blurb:

What happens when we lose someone we love? A death, a separation or the break-up of a relationship are some of the hardest times we have to live through. We may fall into a nightmare of depression, lose the will to live and see no hope for the future. What matters at this crucial point is whether or not we are able to mourn.

In this important and groundbreaking book, acclaimed psychoanalyst and writer Darian Leader urges us to look beyond the catch-all concept of depression to explore the deeper, unconscious ways in which we respond to the experience of loss. In so doing, we can loosen the grip it may have upon our lives.

Pain and fortitude

Yesterday I went under general anaesthetic for the first time, to have a dental cyst removed. While waiting to be called to the theatre I read these comforting words by the great Oxford philosopher, R. G. Collingwood:

I would go so far with the hedonist as to say that anything good is pleasant. Any activity which I definitely choose to go in for, so far as my experience goes, yields me feelings among which there is pleasure, And I will add that although the pleasure sometimes comes as a surprise, a by-product which I had not expected, this happens more and more rarely as I become more and more experienced and acquire (as I hope I do acquire) more and more savoir vivre. Experience of life teaches me to expect the unexpected; in this case, to expect that I shall get pleasure out of things which, if I had been less experienced, I should not have thought likely to prove pleasant. A child may undergo dental surgery and find little in it except pain; when more advanced in years, he will find that bearing the pain gives him a curious and seemingly perverse but unmistakable pleasure; still later, he may learn to expect and reckon on the pleasure. This is not masochism. It is not a pathological enjoyment of merely being hurt. Being hurt is one thing; fortitude under pain is another. So the masochistic enjoyment of pain is one thing; the pleasure of finding that a certain degree of pain does not destroy one's fortitude is another. (pp. 426-7, 'Goodness, Rightness, Utility', The New Leviathan, Clarenden Press 1992)

With modern anaesthetics and pain-killers, in my case little fortitude was required.

Shadows in Wonderland

From the press release of a book coming out next month:

When television producer Colin Ludlow is admitted to hospital for an operation, he expects to be home in ten days. In the event, he ends up staying for five months, nearly dies on several occasions, contracts MRSA and is still recovering from his operation more than four years later.

His perceptive and frightening new book - said to be ‘memorable’ by The Bookseller - Shadows in Wonderland: A Hospital Odyssey is a moving account of how Ludlow pieces together the shattered fragments of his life and seeks to make sense of them again.

Shadows in Wonderland does not only recount Ludlow’s personal struggle for his health in many poignant passages:

“In the days following my surgery, I have a series of unexpected complications and my temperature soars. Eventually I am carted off to the hospital’s Intensive Therapy Unit where I spend several days unconscious on a ventilator. I have a second operation and then suffer massive internal haemorrhaging. Over one tumultuous weekend, I am given 45 units of blood in transfusions. Eventually, the doctors decide to try a rare clotting agent in a desperate attempt to staunch my bleeding, and Anna is told that if this fails to work by the second dose then there is no further hope for me. My children respond to the warning of my imminent death with storm-hardened calm. They are used to grim news by now.”

The book also takes a philosophical and questioning journey through chronic illness as Ludlow explores its wider significance. It is the record of a quest - which we all face - for health and wholeness in a fractured, disjointed world.

In the account of his blistering experience with chronic illness and the NHS Colin Ludlow manages to write masterfully and credibly about the institution, the culture and its history. With its amalgam of one man’s heart-rending experience within the NHS and its illuminating, witty digressions on the place of hospitals and health within Western society, Shadows in Wonderland enlarges our understanding of how it feels to become a long-term hospital patient.

Colin Ludlow also runs a blog.

Placebos and body shape

My friend John Baez pointed me to an interesting news story. This reports research on the effects of explaining to hotel maids that they do more exercise than the recommended daily amount. The odd thing is that many such workers' bodies don't reflect this physical activity, and at the same time they report themselves as doing little exercise. When one randomly selected group had the truth explained to them, there was a decrease in their weight and waist-to-hip ratio - and a 10 percent drop in blood pressure.

Naturally, one might think that this information must have altered other aspects of the maids' lives. Perhaps they were now behaving in a healthier way. An expert is wheeled in to suggest this must be so as the placebo effect only alters subjective aspects of health.

With all the evidence available (some touched on here, here, and here), could it be that the belief that placebos only effect one subjectively is a defense against the troubling thought that language can have an effect on our body?

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.