Psychosomatic medicine and the psychologising of physical diseases

[Hoopoe]

I had an interesting and long conversation with a journalist a couple of days ago. She asked me if I was really saying that I did not think that psychology influenced any illness. That needs a lot of unpacking as we know but I decided that the answer to her question in her terms was YES, that is my position. I was really saying that I did not think that 'psychological factors' affect illness. It surprised even me to say that but if I go through the illnesses - cancer, rheumatoid, diabetes, schizophrenia (yes schizophrenia), stroke, chronic bronchitis... the answer is always no. Asthma could perhaps be an exception but I am pretty doubtful.

I had panic attacks and I think they are an example of thoughts influencing symptoms (but not an example of thoughts causing illness). Being frightened by the horrible sensations it produces would make the sensations worse. I believe they are caused by a sudden and inappopriate catecholamine release which is frightening. I had my first one during an ACTH stimulation test.

 

[Esther12]

I had an interesting and long conversation with a journalist a couple of days ago. She asked me if I was really saying that I did not think that psychology influenced any illness. That needs a lot of unpacking as we know but I decided that the answer to her question in her terms was YES, that is my position. I was really saying that I did not think that 'psychological factors' affect illness. It surprised even me to say that but if I go through the illnesses - cancer, rheumatoid, diabetes, schizophrenia (yes schizophrenia), stroke, chronic bronchitis... the answer is always no. Asthma could perhaps be an exception but I am pretty doubtful.

The problem I see is that the reports of recovery that Lucibee rightly says are real lived experience are irrelevant. Either the person was getting better anyway or what has changed is an unhelpful belief. And yes I do think people have unhelpful beliefs - people like Paul Garner and a whole lot of people I know whose lives are limited by believing silly things about what affects what.

I agree with Sean that the PACE trial would have picked up real causation of recovery if it was there. The lived experience of getting better is NOT a lived experience of being made better. That is an interpretation, not an experience.

But I also agree with E12 that it may be extremely difficult to distinguish people with PEM from people who, because they believe they have PEM because they believe they have a specific disease called ME, report the same symptom. Which is why criteria are so useless - they are not going to discriminate between symptoms and belief. If anything one would predict that people with inappropriate beliefs about having a specific illness are likely to fit the criteria (if subjective) better than those who actually have it.

The crux of my debate with the journalist is that 'psychology' is the study of thoughts - of events we are aware of. Its bogus application to 'unconscious thoughts' i.e. brain processes that we are not aware of, by Freud was a pseudoscientific disaster. A psychological component to an illness is a thought the person is aware of that actually produces new symptoms. Pretty much all of the plausible situations I can think of fall to either one or other side of that. There is malingering. There is belief in having an illness that you do not have or does not exist, and so on. But if people think they are trying to get better, then they are, and the PWME I meet on this forum are.

In other words: physician/psychiatrist manqué, heal thyself.

What about things like panic attacks, fainting at the sight of blood, etc - they would seem to me to be examples of people feeling ill at least partly for psychological reasons, even if we're not really aware of the thoughts? Also, if peoples' lives are limited by inaccurate beliefs about their symptoms and how to respond to them, doesn't that mean that there is a psychological aspect to their ill health?

I wonder if you might be using some words in an unusual way here?

One concern I have about this topic is that it often involves trying to communicate complicated ideas with words that people often use in different ways. Combined with the other difficulties here it routinely ends up being an unhelpful issue for advocacy efforts imo.

 

[Snow Leopard]

It surprised even me to say that but if I go through the illnesses - cancer, rheumatoid, diabetes, schizophrenia (yes schizophrenia), stroke, chronic bronchitis... the answer is always no. Asthma could perhaps be an exception but I am pretty doubtful.

There can be a clear behavioural component, in terms of risk (eg smoking for lung cancer, or diet for type 2 diabetes) and treatment compliance (if you don't seek treatment for a severe cancer...)

But perhaps that is not what you mean?

 

[Jonathan Edwards]

I wonder if you might be using some words in an unusual way here?

I was very careful to start with some caveats. Firstly that the topic needs a lot of unpacking. Secondly that I was trying to respond in the sense that the journalist used the phrase and wanted my opinion. I think @Peter Trewhitt hits the nail on the head here.

I suspect, perhaps because of the nature of human consciousness, that many people, without even realising it, have at least some beliefs that thoughts alone can cause things to happen in the material world. It is in effect a belief in magic, that some how things will happen because we want them too.

I was specifically being asked whether or not I thought some magical 'mind person' hidden inside could alter bodily disease because the journalist wanted to think in those terms.

The reason why the BPS people are supported by the press is that an awful lot of journalists, like a lot of other people, but maybe even more so, believe in minds affecting bodies as per magic. Paul Garner is the epitome of this view within the profession. But it is widespread.

Fainting does not count as psychological. It is a reflex like taking your hand away from a hot stove before you even feel the heat. It has nothing to do with desire or belief. Nobody wants to fall on the floor. I agree that panic is self-amplifying. Fear causes more fear and makes sensations much more salient but I really don't think it causes new symptoms.

I agree that this is a very complicated subject. I write papers on this stuff for the Journal of Consciousness Studies. The key point is that there is no 'person' that can influence a body but the human brain has evolved to support a belief that there is. The idea of magic is imprinted in our neurons by our DNA because it makes sense of a dynamic set up that otherwise requires decades of study to even get to make sense.

But the interesting thing was that the journalist was, unlike the slithery BPS people, being up front that by psychological they meant a magic effect of person on body and that, as a belief in the general population, is what we are up against.

 

[MSEsperanza]

There can be a clear behavioural component, in terms of risk (eg smoking for lung cancer, or diet for type 2 diabetes) and treatment compliance (if you don't seek treatment for a severe cancer...)

Or exposing oneself to allergens if they could be avoided.

Or downplaying one's own illness.

I don't want to downplay my ME but it happens regularly because I have difficulties to accept that I am as sick as I am. That causes PEM more often than needed. Not adapting to the restrictions that my illness gives me at least makes symptoms worse.

I do that despite I know of the consequences.

And maybe thinking that exercise can cure can contribute to illnesses, too?

So in my layperson understanding of psychological factors for illnesses there are indeed on the one hand harmful beliefs and on the other hand harmful emotions or feelings. If you don't know how you can avoid allergens or don't want to due to irrational reasons seem to be two different things. Health education could help with the former. For the latter maybe counseling could help, e.g. in better realizing where pragmatic support is needed and how that could be organized.

The reason why the BPS people are supported by the press is that an awful lot of journalists, like a lot of other people, but maybe even more so, believe in minds affecting bodies as per magic

I always thought a big part of general psychology dealt with the question why people behave irrationally, and a big part of clinical psychology dealt with emotions and how emotions and thoughts relate. Shouldn't psychologists and psychiatrists of all people be aware of that concept of magic minds?

 

[Jonathan Edwards]

Shouldn't psychologists and psychiatrists of all people be aware of that concept of magic minds?

They should be very aware of it but not believe in it!
-ologies are supposed to discard magic.

 

[Daisybell]

Are there any situations where the behavioural component results in something other than a heightened reflex? I’m thinking along the lines of fainting, vomiting etc...

 

[Jonathan Edwards]

Are there any situations where the behavioural component results in something other than a heightened reflex? I’m thinking along the lines of fainting, vomiting etc...

What would a behavioural component be though? That seems to beg questions.

 

[Amw66]

Are there any situations where the behavioural component results in something other than a heightened reflex? I’m thinking along the lines of fainting, vomiting etc...

I don't think you can think yourself better . Perception and actuality are often different , perhaps ironically because we want them to be. We want to " feel" better, and this basic need is being exploited.

Many adjust to illness and the datum of what is " well " is forgotten due to time and memory ( eg my daughter can't remember what it is to not be ill ie what " normal constitutes- this is why I am concerned re EC' s latest crusade to redefine recovery ) .

Being well may be as others have said being 80 to 90 % recovered. The lifestyle change necessitated by some illness recalibrates life, the datum has changed .

I think there is mileage in stress being a significant player for some in developing illness which with regular exposure could become chronic . The body perceives this altered state as the new normal .

Continued / constant exposure to stress may push epigenetuc switches . Fight / flight / freeze affects many functions : glucose metabolism, gut absorption, blood pressure etc. Mouse models ( yes I know mouse not human) have indicated this can throw epigenetic switches and in mice at least , it can be hereditary.

It may be a contributing part of gradual onset where people have lived in stressful situations for a long time like @NelliePledge , or where multiple stressor are involved ( eg puberty where physical changes and emotional stress may contribute )

If we could all think ourselves better, either by ourselves or via a defined programme there would simply not be the level of illness there is.

That recovery so often seems to be redefined post hoc speaks volumes.

 

[Kitty]

I don't think you can think yourself better

Of course not. The confusion often seems to be between how psychology can affect a person's experience of a condition, rather than the condition itself.

Take attitudes to signs and symptoms. Sharpe and his chums deliberately gloss over the issue of which people can safely try to live with, and which are giving them important information. They seem to suggest PEM be treated like tinnitus or male-pattern balding: not much we can do about it, dearie, and you'll feel much better if you accept it and learn to focus on something else.

 

[Tia]

I don't think we should allow the debate about how ME is treated to be tied up with the debate about whether psychological factors can influence physical health. For a start, we're clearly not all in agreement about the latter. But also, I think we're going to lose if part of our argument is that psychological factors don't impact physical health because this is so widely accepted today and it's a key part of the mental health awareness narrative. And actually, I think its such a nuanced and complicated philosophical area that it doesn't translate into clear advocacy.

For me, I believe that there is no clear distinction between mind and body and one can influence the other. I want people to know that I do not reject Sharpe's theories purely and simply because they are psychological but because of the specific issues with his model and treatments. I want to stay very specific about what is wrong with his theory and his research. I think this is reasonable. His particular psychological model of ME doesn't fit with the experience of so many patients, his treatments don't work for many of us and of course the research is flawed - that's the problem, it's not a philosophical dilemma about the mind/body divide.

It seems that a lot of the comments under the Monbiot article is people saying 'but psychological factors do impact on physical health'. As I've said above, I don't think they're wrong, I just think they're mistaken about how relevant that is to our particular situation.

I think it plays into Sharpe et al's favour if we get side tracked into a philosophical debate instead of focusing on the specific problems with their research.

[sorry, cross posted, this isn't about the video Andy has just posted which I haven't watched yet!]

 

[Barry]

So there are very well recorded cases of soldiers before battles being so terrified they vomit, and lose control of bladder and bowels. So fear/terror can definitely trigger these very physical responses. But I'm guessing that is nothing to do with the thought processes involved, but instead an evolved brain/body interaction that is way below the level of emotions and conscious thought. And it occurs in animals also I believe.

But then you might argue that if someone genuinely is paranoid, and very fearful of things that genuinely do not exist to be fearful of, then they might also experience those symptoms. But it would be important to then segregate out the distinction between what the unhelpful beliefs are causing and what then is causing the physical symptoms.

The causal path is indirect: Paranoia -> fear/terror -> physical symptoms

But not: Paranoia -> physical symptoms

 

[Hoopoe]

So there are very well recorded cases of soldiers before battles being so terrified they vomit, and lose control of bladder and bowels. So fear/terror can definitely trigger these very physical responses.

These responses are very different from the problems that are typically labelled psychosomatic illness. That's why I think such examples are not a proof of concept of psychosomatic illness.

Psychosomatic illness is unexplained illness with no clear cause, while these bodily reactions have a clear cause and are easy to explain. The people affected will tell you the cause. These bodily reactions also don't last long. In contrast what is labelled psychosomatic illness is often long lasting or lifelong, and the patients don't believe it's psychosomatic or believe so only due to social spread of this idea.

 

[Tia]

So there are very well recorded cases of soldiers before battles being so terrified they vomit, and lose control of bladder and bowels. So fear/terror can definitely trigger these very physical responses. But I'm guessing that is nothing to do with the thought processes involved, but instead an evolved brain/body interaction that is way below the level of emotions and conscious thought. And it occurs in animals also I believe.

But then you might argue that if someone genuinely is paranoid, and very fearful of things that genuinely do not exist to be fearful of, then they might also experience those symptoms. But it would be important to then segregate out the distinction between what the unhelpful beliefs are causing and what then is causing the physical symptoms.

The causal path is indirect: Paranoia -> fear/terror -> physical symptoms

But not: Paranoia -> physical symptoms

So thoughts don't cause the physical symptoms but emotions do. (Fear is an emotion.) But thoughts are intrinsically linked to emotions - thoughts can cause emotions, emotions can give rise to thoughts - so the distinction is not clear.

 

[Snow Leopard]

I want to stay very specific about what is wrong with his theory and his research. I think this is reasonable. His particular psychological model of ME doesn't fit with the experience of so many patients, his treatments don't work for many of us and of course the research is flawed - that's the problem, it's not a philosophical dilemma about the mind/body divide.

It seems that a lot of the comments under the Monbiot article is people saying 'but psychological factors do impact on physical health'. As I've said above, I don't think they're wrong, I just think they're mistaken about how relevant that is to our particular situation.

I agree that we should take care not to get caught up in this side debate about mind-body dualism or "not psychological", because that debate is irrelevant!

 

[Esther12]

Fainting does not count as psychological. It is a reflex like taking your hand away from a hot stove before you even feel the heat. It has nothing to do with desire or belief. Nobody wants to fall on the floor. I agree that panic is self-amplifying. Fear causes more fear and makes sensations much more salient but I really don't think it causes new symptoms.

But can't that reflex can be shaped by cognitions?

eg whether or not someone felt faint on the news that someone had died would be affected by the persons' cognitions and feelings about the person.

So there are very well recorded cases of soldiers before battles being so terrified they vomit, and lose control of bladder and bowels. So fear/terror can definitely trigger these very physical responses. But I'm guessing that is nothing to do with the thought processes involved, but instead an evolved brain/body interaction that is way below the level of emotions and conscious thought. And it occurs in animals also I believe.

And isn't it still the thought process that would lead to the evolved response? How else would they know that they were about to go into battle? Anxiety can be affected by cognitions and behaviour (though that's certainly not to say that problems are just a result of cognitions and behaviour).

I can see the view that a lot of these responses are in themselves not what some would consider 'psychological', but they're often still shaped by the individual's understanding of the world around them and surely that understanding would be considered a part of the person's 'psychology'.

 

[Invisible Woman]

Sorry if the conversation has moved on but as it's an argument that keeps coming up -

There can be a clear behavioural component, in terms of risk (eg smoking for lung cancer, or diet for type 2 diabetes) and treatment compliance (if you don't seek treatment for a severe cancer...)

But perhaps that is not what you mean?

Or exposing oneself to allergens if they could be avoided.

Or downplaying one's own illness.

As I see it there's a) the illness, there's b)what you think & how you perceive it & the way it affects you and c) hiw you manage the condition.

So let's say type 1 diabetes, how you perceive it may affect how you manage it and can make it as bad as it can be or help you live as normal a life as possible but won't change the fact you have the underlying condition.

Now lets take type 2 diabetes, caught in time, how you perceive it and manage it can reverse it. Is it psychosomatic though? No, I don't believe it's generally considered that way these days. Plus, the improvements can only be maintained if you continually alter your diet and lifestyle to stay well.

So how we think and feel about an underlying condition can affect how we manage that condition and, in some cases, even reverse that condition as long as we permanently change the way we behave. Even though other people do not have to behave the way we do to stay well.

Is there any condition where simply changing how we feel about it cures the condition itself? Not that I know of. Any conditions that have historically been thought of that way have been proven to have physical causes that need to be addressed.

This area where thoughts and feelings affect how we manage a condition is conflated into the idea our thoughts and feelings directly affect underlying pathology. This confusion is deliberate on the part of BPS.

Edit - messed up a quote & missed end of a sentence

 

[Jonathan Edwards]

But can't that reflex can be shaped by cognitions?

eg whether or not someone felt faint on the news that someone had died would be affected by the persons' cognitions and feelings about the person.

NO I think this is where the bogus science blankets almost everything. There is no such thing as a 'cognition' or indeed an 'emotion' in science.

Science deals with dynamic causal processes - what we call body if you like. It also all the time deals with experiences - thoughts, feelings, etc. There is a myth that science does not even deal with experience but my paper in J Cons Studies last month lays that to rest - with the help of a quote from Einstein, who regarded all physics as merely a way of relating experiences.

What science does not deal with are these magical concepts popular with the lay population and reified by 'psychology' as 'cognitions'. These are not dynamic processes based on neurons or signals, nor are they the experiences and thoughts that we think are caused by the signals. They are an entirely phoney concept of some other 'mental' causal entity that nobody in real science, not even Descartes, should take seriously.

Yes, there must be processes in brains that lead to thoughts and since we cannot at present describe them in terms of neurons and signals it is not unreasonable to give them functional names like emotions or cognitions. But two things immediately become clear.

One is that these terms conflate experiences and processes in such a way that honest psychologists admit that the term 'cognition' has no useful meaning. Is fear an emotion or a feeling or a thought - people use it to mean all there and generate non sequitur arguments by sliding from one meaning to another.

The other is that we have no workable theory of dynamics for cognitions. What psychologists have are the bendy always-right theories of the type Freud invented where you can explain anything by bending the predictions however you like. That is what clinical psychologists spend their lives doing without apparently realising that there is no backbone to what they are doing. It is all bullshit.

Moreover, something of crucial importance I learnt studying rheumatoid arthritis is that even if you know how biological processes work in the normal situation that does not necessarily give you any way of predicting what happens in a dysregulated situation. Even if psychologists had well tested theories of how 'cognitions' or 'emotions' worked in normal people they would have to start again when forming theories of ill health.

In short both 'folk psychological' explanations of how the mind makes you ill and the professional explanations that wrap them in fancy names are a load of hooey.

And no, as far as I know fainting is an automatic reflex, that is not changed by thinking. As far as we know the thoughts simply accompany the process. Nobody ever found any 'cognitions' in between.

 

[Esther12]

NO I think this is where the bogus science blankets almost everything. There is no such thing as a 'cognition' or indeed an 'emotion' in science.

Science deals with dynamic causal processes - what we call body if you like. It also all the time deals with experiences - thoughts, feelings, etc. There is a myth that science does not even deal with experience but my paper in J Cons Studies last month lays that to rest - with the help of a quote from Einstein, who regarded all physics as merely a way of relating experiences.

What science does not deal with are these magical concepts popular with the lay population and reified by 'psychology' as 'cognitions'. These are not dynamic processes based on neurons or signals, nor are they the experiences and thoughts that we think are caused by the signals. They are an entirely phoney concept of some other 'mental' causal entity that nobody in real science, not even Descartes, should take seriously.

Yes, there must be processes in brains that lead to thoughts and since we cannot at present describe them in terms of neurons and signals it is not unreasonable to give them functional names like emotions or cognitions. But two things immediately become clear.

One is that these terms conflate experiences and processes in such a way that honest psychologists admit that the term 'cognition' has no useful meaning. Is fear an emotion or a feeling or a thought - people use it to mean all there and generate non sequitur arguments by sliding from one meaning to another.

The other is that we have no workable theory of dynamics for cognitions. What psychologists have are the bendy always-right theories of the type Freud invented where you can explain anything by bending the predictions however you like. That is what clinical psychologists spend their lives doing without apparently realising that there is no backbone to what they are doing. It is all bullshit.

Moreover, something of crucial importance I learnt studying rheumatoid arthritis is that even if you know how biological processes work in the normal situation that does not necessarily give you any way of predicting what happens in a dysregulated situation. Even if psychologists had well tested theories of how 'cognitions' or 'emotions' worked in normal people they would have to start again when forming theories of ill health.

In short both 'folk psychological' explanations of how the mind makes you ill and the professional explanations that wrap them in fancy names are a load of hooey.

And no, as far as I know fainting is an automatic reflex, that is not changed by thinking. As far as we know the thoughts simply accompany the process. Nobody ever found any 'cognitions' in between.

A lot of that seems like semantics - and I don't mean that in a remotely dismissive way. Trying to tightly define things can be really useful, but when talking with others about topics where our language and common understandings often are a bit confused it's easy to be misunderstood if you're using language unusually. To some extent I feel that it's most useful for myself to use terms in their widely understood sense, with a recognition that this is an area where our shared language has serious limitations - though that may just be an excuse for laziness.

"And no, as far as I know fainting is an automatic reflex, that is not changed by thinking. As far as we know the thoughts simply accompany the process. Nobody ever found any 'cognitions' in between."

Whether you talk about 'cognitions', 'experiences' or an individual's 'psychology', there are things to do with their understanding of the world which seem to affect a propensity for responding to particular information by fainting - isn't that right? I've not looked at any evidence of this, but it often relates to such rare and extreme situations that it's difficult to see an experiment for this being performed ('we then killed the parents of those in the active intervention group...'). I thought it's not that amazingly rare for people to feel faint on hearing news of the surprising death of a loved one, or something similar to that. Isn't that an example of 'psychological factors' affecting health?

 

[Jonathan Edwards]

Whether you talk about 'cognitions', 'experiences' or an individual's 'psychology', there are things to do with their understanding of the world which seem to affect a propensity for responding to particular information by fainting - isn't that right? I've not looked at any evidence of this, but it often relates to such rare and extreme situations that it's difficult to see an experiment for this being performed ('we then killed the parents of those in the active intervention group...'). I thought it's not that amazingly rare for people to feel faint on hearing news of the surprising death of a loved one, or something similar to that. Isn't that an example of 'psychological factors' affecting health?

But you are conflating. What is 'understanding of the world'. The philosopher of mind Tim Crane has written quite a bit about this but the key thing is that there are two quite different aspects to beliefs and other so-called 'propositional attitudes'. There is a dispositional state that is there even when you are asleep - so when you wake and go to the door hearing a knock you faint on hearing a relative has died before you have even thought about it. Then there are the states of belief that we are aware of - as when we answer 'I believe so, yes'.

Some years back I wrote a paper in Frontiers in Psychology dissecting the various forms of mental representation involved. Any meaningful causal analysis has to separate the various meanings of 'understand' or 'believe' before you can producing anything that has scientific value. Goodexperimental psychologists know all about this and work with it but clinical psychologists by and large have no clue.

Certainly, we faint on hearing that a relative has died. I cried when I heard that my daughter was born by caesarian in the next room. But strangely I felt no equivalent emotion. I was tired and relieved. The journalist I spoke to said that her hair fell out when her mother died despite the fact that she felt no stress, only relief. She suggested that the hair falling out must have meant that really she was stressed. But what could that mean, since 'being stressed' also means the feeling of being stressed that was absent.

In other words, even in familiar experience of major life events what turns out to happen does not even make sense in terms of folk psychology. If the cognition or emotion of being stressed is defined as that which makes one feel stressed then it isn't whatever causes something to happen without that feeling.

Because none of this is testable both the lay community and the clinical psychologists get away with these magic stories about emotions and cognitions. OK, there must be some processes that link up in a fairly predictable way but in fact if I look back over the numerous personal disasters I have suffered the common pattern is that the folk psychological account gets what happens wrong most of the time. And when you start talking about bipolar disorder it goes completely out of the window.

What everyone needs to see and maybe Mr Monbiot is getting taste of, is that Popper was right - right down to the boots. All this stuff about cognitions is bullshit big time. And maybe it is not so surprising that if you work in a speciality that is based entirely on bullshit that you bullshit about your research.