It’s all in your head

Psychosomatic illnesses aren’t real, or so we think. But, says James Marriott ,as anyone who’s ever wept knows, our state of mind absolutely affects our bodies.

Recently we’ve accepted the idea that the suffering of mental illness, though different from a broken leg or a virus, is real. The next taboo is surely psychosomatic illness (or functional disorder, to use the term doctors prefer). These are the physical illnesses that do not show up in scans or tests, whose causes appear to be ‘‘all in the head’’ but whose symptoms can be severe and terrifying: seizures, fainting, terrible pain, paralysis – even blindness.

A third of outpatients in neurology and gastroenterology suffer from psychosomatic illnesses and it has been estimated that, in the US, they cost more to treat than diabetes. Treatments are often unsuccessful and many patients find themselves shunted from specialist to specialist in search of the one thing in modern medicine that will buy you respect: a label for a disease and proof of its biological cause.

Social stigma persists; sufferers from psychosomatic illnesses are widely considered to be faking it or seeking attention. These, of course, are the same sort of prejudices that were once associated with mental illness.

Strangely, the pandemic may help us break this next taboo. Though not everybody has had Covid-19, nearly everybody has at one time or another wondered whether they have it. The train of thought that runs ‘‘Do I have a cough? A fever? A headache?’’ is almost universally familiar. So is the niggling doubt: ‘‘Is this just in my head?’’

These glancing encounters with the fact that it is possible to experience physical symptoms because you’ve been worrying about them or because there are signals in your cultural environment (alarming news reports, government adverts) that lead you to expect them might be the push we need to get our heads around psychosomatic illness.

After all, there is surely no special reason why our sympathy for a person’s pain or distress should be extended or withheld depending on its cause. Suffering is suffering.

People with psychosomatic illnesses are unfortunate in the fact that their condition offends Western ideas not just about illness but who we are. Dualism – the idea that mind and body are distinct – has a long history in Western philosophy and is fundamental to the way most of us think about ourselves. Our minds are airy, ethereal, separate; our bodies are a sort of machine for which the doctor is a mechanic.

But as almost every medic I spoke to for this piece was keen to point out, this assumption fails to pass even the most cursory examination of our day-to-day lives. Spraying water from your eyes in response to bad news is an example of a psychological state causing a physical one. So is the phenomenon of staving off a bout of illness until after you’ve completed an exam or an important piece of work.

In fact, as the neurologist and expert in functional disorders Professor Jon Stone explains, all illnesses exist somewhere on a spectrum of psychological and physical causes, something people have trouble ‘‘wrapping their heads around because of dualistic ways of thinking and language’’.

Stone points out that sufferers from Parkinson’s disease, a physically manifested illness with an identifiable biological cause, respond dramatically to placebos. This means the psychological experience of a physical illness (in this case whether or not you believe you’re being treated) affects the way that illness manifests itself. Stone says, for Parkinson’s patients, ‘‘the relationship between the severity of the disease and the experience of disability is not as close as they or many doctors think’’.

In fact, he says, it’s possible to argue that psychological illnesses such as depression and anxiety are the ones that are ‘‘a bit weird’’, focusing as they do on ‘‘cognition and emotions in an abstract way’’.

In a world where psychological and physical causes are entwined, psychosomatic illnesses don’t look so strange.

Another challenge to our understanding of functional disorders is our individualism. Though universal in human beings, psychosomatic illnesses are rooted in cultures and societies. Resignation syndrome, a disorder that causes children to fall asleep for years, occurs almost exclusively in asylum-seeking families in Sweden. The illness seems to be spread by reports of its existence. In France, you can buy remedies for a common minor syndrome called ‘‘heavy legs’’ in most pharmacies. No other country seems to experience ‘‘heavy legs’’.

This is not something that makes much intuitive sense to Western citizens, who are accustomed to thinking of themselves as isolated units moving alone through the world.

Not only are the causes social but so are cures. The neurologist Suzanne O’Sullivan points out that a functional disorder called grisi siknis (crazy sickness), which is common among girls of the Nicaraguan Miskito people and causes hallucinations, tremors and superhuman strength, is successfully treated with rituals and the community ‘‘rallying around’’.

Secular, atomised Western society has no equivalent treatment. In the West, illness – especially psychosomatic illness – is likely to make you even more isolated.

One social change that might help is the removal of stigma. As Stone says, the important first step towards a cure (which might involve, for example, a combination of physiotherapy and psychological therapy) is for the patient to accept the diagnosis – not something that is always easy in a culture that so readily associates real disease with biological causes.

Now that stigma against mental illness is breaking, this could be our next big battle.