The Sickening Mind: Brain, Behaviour, Immunity and Disease

Several other physical causes besides viruses have been proposed. One theory maintains that the primary symptoms of CFS are produced by hyperventilation – that is, abnormally rapid breathing. The evidence, however, is once again scant. Only a minority of CFS sufferers hyperventilate. On another tack, research at Johns Hopkins University in Baltimore has indicated that certain types of chronic fatigue (though not necessarily all cases of CFS) might result from abnormally low blood pressure. Yet another suggestion has been that CFS stems from a form of neurobiological disorder. One study revealed that more than a quarter of CFS patients had abnormal brain scans, and subtle changes have been found in the levels of neurotransmitter substances in the brain.

At present, the most favoured physical theories about the origins of CFS revolve around the immune system. There is growing support for the view that the symptoms of CFS result from a perturbation or abnormality in the sufferer’s immune system. This immunological malfunction, it is argued, may be triggered by a viral infection which somehow throws the immune system out of kilter.

Evidence that CFS involves an immunological disorder is accumulating rapidly. Within the past few years various abnormalities have been found in the immune systems of CFS sufferers. These include alterations in the activity and surface structure of two important types of white blood cells: the natural killer cells and T-lymphocytes. (You will be hearing much more about these cells in later chapters.) It is becoming increasingly evident that CFS is associated with, if not directly caused by, a persistent, low-level activation of the immune system.

If CFS really is an immunological disorder then why do some perfectly sensible scientists and physicians persist in regarding it as primarily a psychological disorder? They persist because there is highly respectable evidence to support their viewpoint as well.

Several of the symptoms associated with CFS are also seen in psychiatric illnesses, notably depressive and anxiety disorders. A substantial proportion of those who seek medical help for chronic fatigue turn out to have a recognizable psychological problem. The authoritative Centers For Disease Control and Prevention in the USA has concluded that approximately 45 per cent of all CFS sufferers have some form of identifiable psychiatric disorder before the onset of CFS. Researchers at the University of Connecticut School of Medicine found that as many as three out of four of the chronic fatigue cases they examined could be more easily explained by psychiatric problems such as depression. To add to the picture that the mind plays a central role in the illness, Australian researchers have discovered that CFS patients exhibit significantly more signs of hypochondria than other medical patients.

Psychological theories of CFS have tended to focus on depression. Over half of all CFS sufferers exhibit clear signs of clinical depression. Often the depression appears to have preceded the chronic fatigue, suggesting that it might be a cause rather than a consequence of the syndrome. Severe depression is usually accompanied by prolonged reductions in physical activity which could, in turn, lead to a debilitating decline in muscle function. People who lie in bed for long periods become physically weak. The sleep disturbances that typify some depressive disorders might also exacerbate the sufferer’s fatigue. Furthermore, it is known that severe depressive disorders are associated with changes in the immune system.

But hold fast. It is equally clear that many CFS sufferers become depressed as a consequence of their illness. It is hardly surprising that those suffering from a debilitating but unexplained illness should become depressed and abnormally preoccupied with their health. Although more women than men suffer from CFS this should not be interpreted as evidence that CFS is primarily a psychological disorder, as a few sexist pundits have implied. There are several perfectly respectable organic diseases, such as rheumatoid arthritis, which show a marked preference for one sex over the other.

At present it is probably safe to conclude that the case for CFS being primarily a psychological disorder remains unproven. The evidence for some sort of immunological malfunction is too good to dismiss. There is, however, no doubt that CFS sufferers’ psychological reactions to their illness do have an important bearing on their wellbeing and recovery. Whether depression is a cause or an effect of the syndrome, it becomes a major problem in its own right and can seriously impede recovery.

The controversy over CFS is further complicated by the attitudes of those who suffer from it. People who are afflicted by a serious and debilitating disorder such as CFS want their illness to be publicly recognized as having a medically respectable cause. For most people this means a physical cause, such as a virus or an immunological disorder, rather than a psychological cause. Any suggestion that their symptoms might result from a psychiatric problem tends to provoke outrage.

This attitude is understandable. Talk of psychological causes often carries with it an unjustifiable connotation that the illness is not quite genuine. There is usually a strong whiff of ‘get a grip on yourself and snap out of it’ in the air. Moreover, even in the late twentieth century there is still a wholly unreasonable stigma attached to mental illness. The average person would rather admit to having a physical illness, albeit a vague ‘mystery’ virus or obscure immunological malfunction, for this absolves them of any accusations of malingering, neuroticism or weakness of character. One unfortunate outcome of this desire for a physical explanation is the tendency, in some countries at least, for CFS sufferers to shop around until they find a physician who will give them the diagnosis they want.

Ironically, it turns out that the CFS sufferers who believe most strongly in a purely physical explanation have greater difficulty in recovering from their illness. This may be because they fail to confront and deal with the psychological problems that invariably accompany the illness.

Evidence to support this conclusion has come from a study conducted by Michael Sharpe and colleagues in Oxford. They found that a form of cognitive behavioural therapy, in which CFS sufferers were helped to re-evaluate their attitudes towards their illness, was of major benefit. More than 70 per cent of CFS sufferers who received the behavioural therapy regained their ability to function normally, compared with a success rate of 27 per cent for sufferers who received only standard medical care.

The pressure to attribute CFS to purely physical causes has also had a substantial influence on how the popular media deal with the subject. Newspaper and magazine articles, TV features and self-help books tend to emphasize physical explanations for CFS and neglect its psychological aspects.

A survey by researchers at the University of London found that 69 per cent of all articles on CFS which had appeared in national newspapers and women’s magazines since 1980 had favoured physical causes, compared to a mere 31 per cent of research papers in scientific and medical journals. There appeared to be a systematic bias in the popular media towards reporting physical as opposed to psychological explanations. Even the choice of name was affected. Whereas scientific papers typically used the neutral term chronic fatigue syndrome, the popular media instead favoured the more medical-sounding myalgic encephalomyelitis (ME).

Similar attitudes apply to other illnesses which, like CFS, have been tarred with the psychosomatic brush. Asthma and allergies are familiar examples. So too are inflammatory bowel disorders such as Crohn’s disease and ulcerative colitis. The pendulum of opinion has swung violently back and forth over the years. Half a century ago asthma was widely regarded as an essentially psychological illness. Nowadays it is normal to play down the role of psychological and emotional factors and instead focus almost exclusively on its immunological mechanisms and physical triggers, ranging from fitted carpets to car exhaust fumes. In truth, there are good grounds for believing that both immunological and psychological factors play important roles in these diseases. Nevertheless, the overwhelming tendency is to opt for one explanation to the exclusion of the other.

As we shall see in subsequent chapters, this centuries-old opposition between mind and body, mental and physical, psychosomatic and organic, is a snare and a delusion. It has impeded scientific understanding and acceptance of some very important phenomena. There is nothing ‘alternative’ or scientifically dubious about the fact that what goes on inside someone’s brain influences their physical health.

2 Shadows on the Sun (#ulink_bb892221-d4c2-5c3e-aead-59e3da7e9bdf)

Had she been light, like you,

Of such a merry, nimble, stirring spirit,

She might ha’ been a grandam ere she died;

And so may you; for a light heart lives long.

William Shakespeare, Love’s Labour’s Lost (1595)

In Tobias Smollett’s epistolary novel The Expedition of Humphry Clinker (1771), Mr Matthew Bramble makes this perceptive observation in a letter to Dr Lewis:

I find my spirits and my health affect each other reciprocally – that is to say, every thing that discomposes my mind produces a correspondent disorder in my body; and my bodily complaints are remarkably mitigated by those considerations that dissipate the clouds of mental chagrin.

Is the centuries-old notion that the mind plays a pivotal role in physical disease an established fact or unsubstantiated folklore? In this chapter we shall consider some of the many strands of scientific evidence for and against that notion. Precisely how the mind affects physical health is a question we shall leave until later. But first we must clear a conceptual hurdle out of the way.

The perfectly sensible idea that the mind can influence our susceptibility to disease is often muddled with the different, but equally venerable, notion that the mind can by itself conjure up phantom illnesses which have no physical basis. We are about to encounter the psychosomatic fallacy.

According to one fairly representative modern definition psychosomatic illness is ‘any illness in which physical symptoms, produced by the action of the unconscious mind, are defined by the individual as evidence of organic disease and for which medical help is sought’ [my italics]. By this definition, the unfortunate victim might feel ill even though he or she has no underlying physical disease. In other words, mental state is the sole and sufficient cause of the physical symptoms. Such things do, of course, happen; we shall take a look at them in chapter 3. But they are not a major concern of this book. In fact, they are something of a distraction.

Psychological and emotional factors can determine whether or not someone becomes ill but they mostly do this by altering that person’s susceptibility to disease. They are rarely the sole and sufficient cause of illness. A less misleading definition of ‘psychosomatic’ is one in which psychological factors play a contributing role in the development of the illness, alongside other factors such as bacteria, high blood pressure or smoking. But by this definition most illnesses in the Western world today can be termed psychosomatic.

The misleading conception of illnesses as mere phantoms, conjured up by the unconscious mind, has its roots in the psychoanalytic theories of Sigmund Freud. According to Freud and his disciples many mental and physical disorders have their roots in emotional conflicts, of which the patient may have no conscious awareness. These unconscious emotional conflicts are translated into physical symptoms such as pain, paralysis or loss of sensation. The symptoms are regarded by the sufferer – though not necessarily the rest of the world – as legitimate signs of a genuine organic illness. This dubious concept of psychosomatic illness lives on and can still be found lurking within the pages of popular health and self-help books.

Freudian psychoanalytic theories laid the foundations for what later became known as psychosomatic medicine, a field which came into being during the 1930s and 1940s. The earliest practitioners of psychosomatic medicine sought explanations for mysterious disorders such as asthma, allergies, arthritis, high blood pressure and peptic ulcers in underlying emotional conflicts and personality characteristics. Psychosomatic theories about asthma, for example, revolved around such notions as the fear of losing parental love. As a natural consequence of their Freudian leanings, many of the early psychosomatic practitioners tried to treat disorders like asthma and allergies using psychotherapy – with fairly mixed results.

We, on the other hand, shall be moving firmly within the realm of ‘real’ diseases like the common cold, herpes, coronary heart disease and cancer, rather than those shadowy and mysterious maladies to which the epithet psychosomatic is usually applied. The diseases we shall be focusing on in subsequent chapters are caused by real bacteria, real viruses, real clogged arteries or real cancer cells. They are most certainly not just ‘all in the mind’.

Death, disaster and voodoo (#ulink_06bab89d-3c55-5a63-9ac3-8b7afd5af61a)

Sometimes – quite often, in fact – people drop dead with little or no warning because something goes wrong with their heart. This phenomenon is called sudden cardiac death. It is normally defined as an unexpected heart failure within twenty-four hours of the first symptoms (if any) being noticed.

Sudden cardiac death accounts for about 15 per cent of all mortality from natural causes. Though victims may have no previous medical history of heart problems, autopsy generally reveals a pre-existing but hitherto undiscovered disease. Unfortunately, in more than half of all cases the first manifestation of this disease is death.

For centuries people have believed that severe psychological stress, grief, fear, anger or other strong emotions can trigger sudden cardiac death. There is massive anecdotal evidence that distressing events such as the death of a loved one, the loss of a job or even a heated argument can trigger a fatal heart attack. In recent years scientists have accrued a satisfyingly solid mountain of systematic evidence to confirm the anecdotes.

When scientists analyse the immediate precursors of sudden cardiac death they consistently find that a large proportion of its victims have experienced unusually high levels of emotional distress in the hours or days leading up to death. One study, for example, found that 40 per cent of men who died unexpectedly from heart failure had experienced a significant emotional upset, such as being involved in a car accident or receiving notification of divorce proceedings, within the twenty-four hours immediately preceding their death. There have even been documented medical reports of individuals dying after being severely disturbed by upsetting thoughts or recollections of a traumatic experience.

One of the most common precursors of sudden cardiac death is the extreme fatigue and exhaustion known as burnout. Like consumption in the nineteenth century, burnout has become something of a bizarre status symbol. Burnout is seen as the ‘red badge of courage’ in professional circles, proof of Herculean labours and overwhelming workloads. (This says a great deal about present cultural values. In the nineteenth century consumption lent status because it supposedly denoted creativity and artistic passion; nowadays it is the sloggers we prize.)

Whatever the cultural overtones, there is a significantly higher risk of sudden cardiac death for victims of burnout. Those who exhibit the classic symptoms of intrusive anxiety, irritability and mental exhaustion may feel that way because of a mechanical fault in their heart. In many cases, however, burnout is more a symptom of prolonged psychological stress. In combination with a pre-existing weakness in the heart or coronary arteries it can easily be lethal. Dutch research which tracked the health of a large sample of middle-aged men over several years found that individuals who reported feeling mentally and physically exhausted at the end of the day were more than twice as likely to die from a heart attack. This was true even for men who had hitherto been free from any coronary heart disease.

In chapter 8 we shall be looking in greater depth at the biological mechanisms whereby the mind can damage the heart and coronary arteries. Suffice it here to say that there are plenty of well-understood biological mechanisms which enable stress-induced changes in the brain to trigger sudden cardiac death, especially where coronary heart disease is already present.

Sudden death can also be provoked by traumatic events on an impersonal scale. We have already considered the case of the Israeli citizens who died during the Gulf War from psychological stress generated by Iraqi missile attacks. Nature has conducted some of its own experiments in stress-induced death. Take earthquakes, for example. An analysis of mortality statistics immediately after a major earthquake will usually reveal a transient rise in the number of deaths from heart failure and other natural causes, unconnected with the direct physical effects of the earthquake. For instance, in 1978 the Greek city of Thessaloniki was hit by two earthquakes. Official records showed a marked increase in deaths from natural causes, especially heart failure. During the three-day period spanning the earthquakes and their immediate aftermath, the rate at which the local population were dying from heart disease shot up by 200 per cent and the death rate from other natural causes increased by 60 per cent.

Similarly, when Australian scientists investigated the aftermath of an earthquake which struck New South Wales in 1989 they found that the incidence of fatal heart attacks in the locality went up by 70 per cent. In these and other cases it was clear that psychological stress had brought about the premature deaths of vulnerable individuals.

Then we have those strange tales of voodoo, or ‘hex’, death. The unfortunate victim is ritually cursed by a witch doctor, voodoo priest, bokor or other symbolic authority figure. Once the death sentence has been pronounced the victim duly obliges by giving up the ghost and dying, usually within a few days. Competent and trustworthy authorities have been documenting instances of voodoo death since at least the sixteenth century, in places as far apart as Africa, South America, the Caribbean and Australia. It cannot be dismissed as the product of lurid fantasies.

The religious and cultural details vary, but reliable reports of voodoo death share certain basic features. First and foremost, the victim must be highly suggestible, with an unquestioning belief in the power of the sorcerer or witch doctor who curses him. He must also be totally convinced that he is powerless to do anything to save himself. An attitude of helplessness is essential: once the bone has been pointed or the curse uttered, the victim loses any will to live. Sceptics, scientists and tourists do not die from voodoo curses. A third important ingredient is social pressure. It speeds things along no end if everyone else in the victim’s social world shares the same beliefs. Family and friends reinforce the victim’s belief in the inevitability of death, abandoning the unfortunate individual to die in complete isolation.

(#litres_trial_promo) The enormous importance of social relationships for mental and physical health is a theme we shall return to later.

Literature is replete with characters who drop dead from the effects of overpowering emotion. Shakespeare’s King Lear, for example, dies of a broken heart when his favourite daughter Cordelia is cruelly murdered shortly after Lear is reconciled with her. On discovering Cordelia’s body, Lear gives vent to his crushing grief:

Howl, howl, howl, howl! O, you are men of stones!

Had I your tongues and eyes, I’d use them so

That heaven’s vault should crack. She’s gone for ever.

Then Lear drops down dead.

Trouble, strife and sickness (#ulink_39fbe3df-67bc-50e5-b212-ae3d39d724a8)