杏吧原创

After the second world war, US and British scientists conducted serious research into the links between mind and body in disease. Psychosomatic medicine was even taught in medical schools. But by the 1970s the textbooks were gathering dust, and most doctors in the English-speaking world are ignorant of the vast literature on this topic. Could this explain why, in half of all cases seen by family doctors, the symptoms cannot be explained purely physically? Psychoanalyst Darian Leader and philosopher of science David Corfield think so. They told Laura Spinney why doctors could treat people more effectively if they opened up to psychoanalytic ideas.

Why revive interest in psychosomatic medicine now?

DC: In the last few decades, excellent mechanistic models have emerged to explain how psychological processes affect the immune and endocrine systems at the molecular level 鈥� models that did not exist when mind-body connections in disease were first explored in the 1940s and 1950s. As a philosopher, I鈥檓 interested in how scientific theories evolve. In my conversations with Darian, it became clear that because of the loss of interest in psychosomatic medicine, we have ended up with a very sophisticated physiology and an impoverished psychology. The psychology has not kept up.

DL: At the same time that we were discussing these ideas, I was seeing cases in which there was physical illness 鈥� an autoimmune disease such as arthritis, say 鈥� and finding that it was sometimes possible to predict when my patients鈥� symptoms would worsen, depending on what they were talking about. There is clearly a link between what is happening in their minds and what is going on in their bodies, something that GPs [general practitioners] were missing.

You鈥檙e talking about somatisation, where psychological distress manifests itself as physical symptoms?

DL: We believe somatisation is a bit of a misleading term, because every illness has a psychological aspect. What matters is exploring this psychological side, even if it sometimes proves negligible. The trouble is, often the patient himself isn鈥檛 aware of his underlying psychological problem. Say someone is blocked in processing a bereavement. He thinks he鈥檚 come to terms with it but he hasn鈥檛, and eventually he falls physically ill. He may go to his GP, who prescribes a pill. The symptoms subside, but later reappear or are replaced by other symptoms. The patient goes back to the doctor, who prescribes another pill. In this process there鈥檚 no thought given to the underlying problem. This is where psychoanalytic ideas can help, by encouraging the person to acknowledge that non-conscious connection.

In your book you make the surprising claim that the more well-adapted and unflappable a person is, the greater his risk of illness. Can you explain?

DC: This goes back to work in the 1970s on alexithymia, a term coined to describe people who have trouble processing or expressing their emotions. Research in many different countries suggested there was a correlation between a propensity to fall ill and the fact that the person showed no emotional reaction to significant events such as death or divorce. They鈥檇 look as if they had pulled their socks up and were carrying on as normal, and then suddenly they鈥檇 fall ill. If it was suggested that the disturbing event and the illness might be linked, they would not see any connection.

Another interesting phenomenon you describe in the book is anniversary symptoms. Can you explain what these are?

DC: We describe the case of a woman with no prior history of angina, for example, who suffered a heart attack on the anniversary of her husband鈥檚 lethal heart attack. In another case, a man鈥檚 multiple sclerosis always became severely exacerbated on the date that his brother had died in a concentration camp. Hundreds of studies were done on anniversary reactions in the 1950s and earlier, but most GPs nowadays have not heard of them.

How do you treat anniversary symptoms 鈥� do you point out to the patient the significance of the date?

DL: No. In the early sixties, researchers excited by psychoanalytic ideas thought that they could cure people just by telling them what they assumed to be their psychological problem. Useless! For psychoanalysis to have any purchase, the patient has to come to recognise for himself associations he might be making at a non-conscious level. That requires a long, drawn-out work of therapy. It might involve seeing a patient three or four times a week over several months or years. There鈥檚 no such thing as a quick fix.

That doesn鈥檛 seem practical for the average GP.

DL: No, but the average GP might at least spot an anniversary symptom if he asked different questions. Rather than asking 鈥淗ow long have you had the problem?鈥�, for example, he could ask, 鈥淲hen did it start?鈥�, and then try to explore what was happening in the patient鈥檚 life around that time.

DC: In a city like London, the average GP consultation lasts between 6 and 8 minutes. Michael Balint, a doctor and psychoanalyst who in the 1950s set up groups in which doctors examined their relationships with their patients, suggested that the initial consultation, at least, should last 30 to 40 minutes. That way the doctor has time to learn something of the patient鈥檚 psychological life. The idea is that it will pay off in the end, by reducing the number of visits the patient makes to the doctor.

Is doctors鈥� neglect of psychological factors a particular problem in America and Britain?

DC: Yes. At the time when interest in psychosomatic medicine was dwindling in the US and UK, it was still going strong in France, kept alive by a psychoanalytic community that was discussing these new mechanistic models of illness. Psychoanalysis is part of French culture, and there鈥檚 more of a dialogue between doctor and patient there. There鈥檚 also more collaboration between doctors and psychoanalysts. But the jury鈥檚 out over whether French doctors have benefited in the way Balint suggested.

How do you explain studies which suggest that, for some people, repressing disturbing memories is the best way to cope with them?

DL: In the research that purports to show that, the measures used are nearly always questionnaires and structured interviews. We believe very strongly that to ask someone who has experienced a distressing event, 鈥淎re you getting on OK?鈥� is not the best way to address their health problems. You need long-term study, the kind of thing that therapy allows. What if the person responds that they are well and happy, and a month later falls ill? The researchers might not see that, and the patient himself may fail to make the link too.

DC: We鈥檙e not saying that therapy is the answer to everything. In many cases a combination of a medical treatment and therapy is appropriate. But when it comes to thinking about human illness, you have a far richer and, we think, more scientific approach if you incorporate the psychological dimension.

Are you in danger of encouraging hypochondria?

DL: The UK鈥檚 National Health Service is swamped by hypochondria now. I鈥檓 not talking about hypochondriasis, which is a serious psychiatric condition, but the milder sort where the body is used as a means of communication. People go to the doctor for many reasons, one of which is to talk. The reason they are increasingly seeking out alternative medicine is largely because they feel they are not properly listened to by GPs.

Should all GPs be psychoanalytically trained?

DL: In utopia, yes! But that would mean all GPs going through psychoanalysis themselves, since that is what psychoanalytic training involves. In reality we don鈥檛 think all GPs will go through psychoanalysis. All we鈥檙e hoping for is a culture in which there is more dialogue between the specialties.