Can illness be ‘all in your head’?

There are certain kinds of illnesses that seem to cause great distress to doctors – and there are certain kinds of patients that medicine seems almost incapable of helping.

It can seem to some people that doctors are almost hostile to them. We often read in illness memoirs of doctors who have been dismissive, and patients being told: “it’s all in your head”, “you’re imagining it”, “your symptoms aren’t real” (whatever that means).

I have in mind a patient I saw last Monday morning. Mr Hutchens (not his real name) has been depressed for many years since losing his job because of his chronic back pain, sustained after an apparently minor road accident. His scans and x-rays and blood work are all normal, except for a wee bit of age-appropriate wear and tear.

But immobility has caused him to put on weight, and then develop type-two diabetes, and this combination of irreversible events has caused his pain to worsen.

He takes tramadol, a powerful, commonly prescribed narcotic painkiller – definitely your go-to drug if you’re recovering from surgery, which was its original purpose, but now it seems prescribed for pretty much everything; and gabapentin – a drug originally licensed for epilepsy, but never quite finding a home, until it was relicensed for pain. Now it seems it is prescribed for, again … pretty much anything.

I had tried to tell Mr Hutchens that his heavy doses of narcotics and sedatives were the problem, not the answer, and he needed to cut down the drugs, take some exercise, and stop smoking.

He then accused me of trying to tell him, in my clumsy way, that his lifetime of pain was “all in his head” and that, somehow, as a consequence, his pain was less real. Which, in a way, I was. Which, in a way, perhaps, it is.

There are things that scientific Western medicine is brilliant at – fixing a broken bone, for example. But medicine isn’t all like that – in fact most of it isn’t.

We have brains attached to these bags of bones, and these contain a whole, different world of experience and perception. In many, even most, cases, we haven’t a hope of curing the distress experienced by these brains if we simply address the metrics of the bodies they’re carried in.

That’s why, however much I up his painkillers, and prescribe new, better, fancier ones, Mr Hutchens’s pain will, stubbornly, never get better.

There is a lack of a mutually acceptable vocabulary with which to discuss how minds and bodies interact, within social contexts, to produce illness. There is something about the either/or way we use to conceptualise the problem that makes attempts to address it fraught with misunderstanding and antagonism.

Relationships between people and their doctors will always be frustrated until we can find a way through this. How to get traction on this big, unanswered question in medicine is the challenge to which Jo Marchant sets herself in Cure.

When writers talk about healing the mind, or spirit, or soul, they often abandon decent standards of evidence and rationality, and stop making sense. But this is Dr Marchant’s territory. Writing with simplicity, clarity and style, and covering an enormous range of material, she surveys with grace what we think we know, and what we would like to know, about the mysterious and troubling relationship between our minds and our bodies.

After a too brief introduction of what has become known as the mind/body problem, she reviews the science of what is understood about the function of placebos, and their extraordinary power to make people feel better.

She says, as anyone who has been loved as a child already knows, that “kissing it better” really does work. But she asks: How? And then pursues the question. What can be the mechanics of such a thing – a release of endorphins?

She develops a deep discussion of how language, meaning and culture determine how people experience illness, and how those in turn determine their responses to technical medicine, ritual, placebos and caregiving. She illustrates this with vivid testimony of her own, witnessing the power of compassionate care in the alleviation of her own pain during childbirth, and contrasting her experiences of technological, hospital, doctor-led obstetrics with a home delivery, performed by a caring midwife, whom she had had the chance to get to know well.

Things take a more contentious direction as she moves to discuss the potential role of hypnosis in the management of irritable bowel, and then to the battleground of chronic fatigue syndrome and the extraordinarily polarising effect that this devastating condition has on patients, their carers and their doctors.

Marchant surveys a range of innovative, nontraditional interventions for the treatment of severe pain, and it is here that she misses a trick. She references, too briefly, the epidemic occurring in the United States of prescriptions for the powerful narcotic oxycodone, for nonspecific pain, then seems to stop just when I wanted her to go much further.

Chronic pain of unclear physical cause is the clearest example that one could ask for of complex, perplexing, mind-body medicine, and our common solution – of doping sufferers with powerful narcotics and sedative anticonvulsants, could well be, in my opinion, the next medical scandal.

From about this point on I became increasingly uncomfortable. She talks about “mindfulness” in medicine, and I flinch a little. She cites research that offers evidence for the physical connectedness of our brains with our immune systems through our vagus nerves, and the potential role for “biofeedback” in the management of … just about everything.

And I begin to think: Really? Near the end we find ourselves in the long queue for the healing waters of Lourdes, investigating the curative power of religious faith and miracles, and my anxiety levels have grown uncontainable and my bullshit detector is going off.

But Marchant is level-headed, always with one foot planted in the world of science and reason. Though open-minded, she is rigorous, her gently sceptical tone reassures, and she gracefully skewers quackery. Many of the claims she makes in her balanced, compassionate book can seem self-evident in retrospect – “believing in an angry or judgmental God seems to make people more stressed” – but are perhaps all the more important for that.

As she says: “Taking account of the mind in health is … a more scientific and evidence-based approach than relying ever more heavily on physical interventions and drugs.” And its neglect by doctors and researchers acts to the detriment of all. – © Guardian News & Media 2016

Peter Dorward is a medical doctor

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