The mind/body dichotomy

I have a long-standing interest in the relationship between the mind and the body. A lot of my life history has drawn me towards it: my psychology degree taught me all about the theory of the mind, chronic illness has taught me how the mind can negatively affect the body (I often experience flares when I am stressed or sleep-deprived, for example), and my yoga practice has shown me the amazing things we can achieve when the mind and body work together in harmony.

But the thing is, the very concept of mind/body bothers me, and the more I think about it, the more confused I get. Where does the mind stop and the body begin? How can we possibly separate them out into two entities that can be described and studied without consideration to the other? Is there even any value in having these two distinct words; what do we gain by treating them separately?

I have recently been studying some of the medical literature about the relationship between physical symptoms and mental ill health, and what stands out for me is that even the experts on this topic, in the Western world at least, treat them as two separate ‘things’. Take for example, this study on the use of psychological interventions for people with emotional disorders and chronic illness. The very first line of the paper says: “Emotional disorder associated with physical illness falls into two main groups: psychological reaction to physical illness and somatic presentation of psychological disorder.” So either a) you have a physical illness and it makes you depressed/anxious etc, OR b) you have a mental illness that just happens to express itself as physical symptoms like tummy aches. But how valid is this distinction, and how useful is it to think about these relationships in such a linear fashion (i.e. A causes B)?

Could we not say, instead, that health is just health, and we all fall on a health continuum ranging from very poor to very good? Anyone who’s ever had depression will know that it can make you feel absolutely terrible physically – you might feel exhausted even though you get 10 hours of sleep every night, you might have constant headaches or migraines, or you might be picking up every bug going around. And anyone who’s ever had a chronic illness will most likely have felt pretty shit mentally at times, because feeling lousy for extended periods of time really does start to drag you down after a while, no matter how good your coping mechanisms. In fact, even an acute illness like the flu can really mess with your head, because as much as the idea of lying in bed all day sounds delightful when you don’t get to do it very often, once you’re forced into it you quickly start to feel like you’re in prison.

I’ve had times in my life where mental illness was my primary health concern and my only diagnosis, and I’ve had other times where my physical health was in a very poor state but my mental health was, all things considered, pretty good. But how much did those diagnoses of ‘mental health problem’ and ‘physical health problem’ really help me? In fact, I think these categories can actually be quite damaging, both for the individual and for our progress in understanding disease. Because the very presence of this mind/body dichotomy means that when a doctor suggests a psychological treatment, it immediately sends a message to the patient that this problem is all in their head. And I know both from personal experience and from the experiences of others with chronic illness, that this can make you feel disbelieved; that you have to somehow defend the physical nature of your illness.

But this attitude means that people who could be benefitting from psychological support are not getting it, because to accept psychological help means you are admitting defeat – if this is in my head, then it cannot be physical. Likewise, I think that having a diagnosis of a mental illness can make medical professionals very quick to discount anything other than that mental illness as a cause of problematic symptoms, adding to the cycle of feeling disbelieved and unsupported.

I dream of a world where this mind/body distinction is a thing of the past. Where we all recognise that the mind and body are intertwined, so much so that we talk about them as one entity without even realising that’s what we’re doing. Where there is no shame in accepting that the way feel in our heads might be affecting the way we feel physically, or vice versa. Scientists don’t know it all, and just because something is widely accepted by very clever people, it doesn’t mean that it is the most helpful way to think about things, or even that it is true. Didn’t the brightest minds in the world once believe that the earth was flat?

 

It’s all in your head

I’ve just finished a book called “It’s all in your head: Stories from the frontline of psychosomatic illness”, by Suzanne O’Sullivan. I picked it up because it is relevant to my PhD, but it turned out to be a very interesting read and one that’s made me think a lot about my own health. It’s quite controversial, there are bits I don’t agree with, and some places where I think the author shows a naivety that is not uncommon among western doctors. However, it really was fascinating and made for easy reading.

I want to briefly digress with a game. I was first shown this during my psychology degree, and it blew my mind! It only lasts just over a minute, but you can read on if you’re not interested. I just wanted to include it for a fun illustration of the power of the mind.

Anyway, back to the book. Suzanne O’Sullivan is a neurologist specialising in psychosomatic illness. A psychosomatic illness is “a disorder characterized by physical symptoms of psychic origin”. I.e. physical symptoms that are considered to be caused by the mind. This dichotomy between mind and body really bothers me. Surely all illnesses involve both the mind and the body, to some extent? Depression is a mental illness but fatigue and appetite change are part of the diagnostic criteria. A heart attack is a physical event, but a period of intense stress or anger can bring one on [1]. Our mind and body are so intertwined that this continuing attempt to disconnect them just seems ridiculous.

The book contains a series of case studies of patients Suzanne O’Sullivan has seen, with a range of debilitating physical symptoms that have been diagnosed as psychosomatic. The wide range of symptoms are quite incredible: seizures, gastritis, migraines, tinnitus, loss of eyesight, paralysis. Patients have given up work, are bed-bound, have spent years undergoing hospital investigations, surgery, taking harsh medications. One thing the author does well is describe just how difficult life has and continues to be for these patients. Their symptoms are not ‘pretend’, they have genuinely disabling symptoms that affect their lives enormously. The core theme running throughout is that, regardless of the individual pattern of symptoms, these patients are at their wits end, desperate to have a diagnosis and a way forward.

This part of the book I can really relate to. My health problems continued for years before I got some answers, and having medically unexplained physical symptoms is difficult for so many reasons. Not having a diagnosis or label makes it hard to explain to other people. It means that you cannot research your own illness, and therefore you feel completely uninformed about what is going on in your body. No diagnosis means, almost inevitably, no cure. It is upsetting, stressful, embarrassing and frightening to have disabling symptoms for which your doctor can find no explanation.

The point in the book is that the search for a physical cause can in itself prolong suffering. Suzanne O’Sullivan says that, once people accept that their symptoms are psychosomatic, they can work with a psychiatrist to understanding the underlying cause, and therefore work towards getting better. Which, surely, is what all of them want? It’s an interesting point, and indeed in the book she describes patients who do get better, and whose quality of life improves hugely through working with a psychiatrist. She makes a case that this is nothing to be ashamed of. The sooner we as a society stop giving less weight to mental health than physical health, the sooner we can all accept the influence of our mind on our body, and we can all work towards living a healthier life.

If someone told me that my symptoms were psychosomatic, that there was no physical cause for them and that I should see a psychiatrist, would I do it? Actually, I think I would. In fact the book has got me questioning whether there could be more of a psychological influence to my illness than I realise, and whether it’s something I should consider. However, I do still have a problem with this way of thinking. Because, at what point should you stop looking for a physical cause? I did get a diagnosis, and a physical cause was found, I have chronic reactivating Epstein Barr which is shown through the particular types of antibodies present in my blood. Actually this is one of the parts of the book that irritates me. The author makes a (very brief) reference to EBV when she discusses chronic fatigue syndrome, stating that since most of the adult population has had it at some point in their life, most people will have EBV antibodies in their blood and therefore EBV antibodies do not mean anything for CFS. This explanation is scientifically incorrect. There are multiple types of EBV antibodies, and the pattern of antibodies demonstrates whether the person has chronic EBV. The bloodwork of someone who has continuous symptoms caused by EBV will be different to the bloodwork of someone who contracted it many years ago and made a full recovery. This is well documented in scientific research and I could pull out many, many papers to this effect. She also makes a comment later in the book that is quite derogatory to people who believe they have food intolerances, and makes a statement that again suggests she does not understand the latest science.

Now, she is a neurologist specialising in psychosomatic illness. She’s not an EBV expert or a food intolerance expert. No-one can know everything, not even doctors. However, it is exactly this attitude that frustrates me about western medicine. There is a belief that the doctor knows best, that their medical training is more important than the patient’s own experience of their body. Despite all of the knowledge gained by science, there is still so much that science doesn’t know. That is exactly what keeps scientists in the job (and exactly why I love working in it) – there is always more to learn. Just because something isn’t recognised by medicine currently, that doesn’t mean it won’t be recognised in 5 years time, and it is arrogant for any doctor to think that what they know now is everything there is to know.

And this is where I struggle with psychosomatic illness. On the one hand, if psychological treatment can help improve a patient’s quality of life then that is great. Clearly physical symptoms CAN originate in the mind. But does this mean that just because a physical cause for someone’s symptoms has not yet been recognised, that they MUST originate in the mind? In any case, the general take-home message of the book is one I definitely agree with. The mind and body are not distinct. We all need to accept that the mind can make us sick. We so easily accept that emotions can affect our body; no-one questions that when we’re happy we might laugh, and when we laugh we make a noise, our breathing changes, our body shakes, the muscles in our face contract…and that these changes happen largely out of our control. So why is it so hard to believe that psychological factors might make us sick?

I have been thinking a lot about this over the last few weeks, about how my own illness may be influenced by my mind. I think it is easy to get defensive about this. For whatever reason, we don’t want to accept that our mind may be influencing our bodies. By accepting that, you are somehow implying that you can control it, that you should be able to ‘snap out of it’ or that you are choosing to be sick. However, if I want to stay true to my own beliefs, to the things I have written about in this post, then I must be open-minded to the idea that those beliefs are relevant to my own situation. Blog post on that coming up.

 

[1] Mostofsky EPenner EAMittleman MA. Outbursts of anger as a trigger of acute cardiovascular events: a systematic review and meta-analysis. European Heart Journal 35(21):1404-10.