The Sickening Mind: Brain, Behaviour, Immunity and Disease
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Perish the thought, but just occasionally some of us have been known to concoct a tactical minor illness to get ourselves out of a predicament – perhaps as an excuse to avoid a dire social occasion or, less blatantly, to justify our poor performance in an exam, at work or in our personal relationships. Outright lying need not be involved. Gentle self-delusion is all that is needed. When sickness becomes an escape route from an unpleasant situation or embarrassment it is all too easy to convince ourselves that the symptoms are genuine. The ‘sore throat’ that conveniently gets the anxious child out of having to perform in the school concert can feel like a real sore throat.
Our minds, like Colin Craven’s, can exaggerate the severity and significance of symptoms, causing us unnecessary distress and wasting doctors’ time. But perceptions can shift in the opposite direction as well. An inert placebo ‘drug’ will often produce startling improvements in a patient’s symptoms – provided the patient believes it to be a real medicine and expects it to have a beneficial effect. (We shall be revisiting the placebo effect later; it is yet another example of why the mind cannot be divorced from bodily health, even when we are dealing with apparently straightforward physical diseases.)
We all have the capacity unconsciously to blot out things we find too uncomfortable or upsetting to think about. This psychological defence mechanism is known as denial. However, the mind’s ability to belittle or even ignore symptoms is something of a mixed blessing. Being excessively stoical or negligent about your own health is risky.
When people react to illness by denying the reality of their symptoms they may save themselves the unpleasantness of confronting an unpalatable reality. But their denial can be positively dangerous if it prevents them from seeking timely medical attention. A woman who fails to notice a lump in her breast, for example, or chooses to disregard it until her breast cancer is at an advanced stage, may pay for her insouciance with her life.
It is an unfortunate fact that people are less likely to seek medical help if it is difficult, inconvenient or embarrassing for them to do so – perhaps because they are too busy, or cannot afford the fees, or because they are simply afraid of calling a doctor out on a false alarm. Heart attacks are notoriously more likely to prove fatal at weekends, when it is inconvenient or potentially embarrassing to seek expert medical help. The lives of countless heart attack victims might have been saved had they not incorrectly attributed their chest pains to indigestion.
The disastrous consequences of denial are sombrely portrayed in Arnold Bennett’s Riceyman Steps. The tightfisted Clerkenwell bookseller Henry Earlforward has cancer of the stomach but steadfastly denies that he is ill. Earlforward insists that it is merely a temporary indisposition and that he has a constitution of iron.
For a long time Earlforward’s wife interprets his lack of interest in food as a symptom of his miserliness rather than any medical problem. Even when it becomes obvious that the emaciated bookseller is gravely ill he obstinately refuses to be examined by a doctor, let alone admitted into hospital. His wife rails at him for concealing from her the seriousness of his illness until it is too late to do anything about it. She tries hard to persuade Henry to accept medical help, but is forced to concede for ‘nobody can keep on fighting a cushion for ever’. Faced with Henry’s bland obstinacy, his wife and doctor eventually abandon their attempts to help him and he dies from his cancer – a victim of his own misplaced psychological defences.
Whether or not an illness has psychological origins it will certainly have psychological consequences. Feeling ill for any length of time is a psychologically debilitating experience. One of the simple but important ideas I hope to convey in this book is that the relationships between mind, body and disease work both ways. The mind affects the body and hence physical health. Conversely, physical health affects the mind and hence our thoughts, emotions and behaviour.
All but the most trivial of illnesses produce some sort of emotional reaction, whether it be mild irritation, anxiety, anger, denial or depression. Other things being equal, a serious illness should provoke a more intense emotional reaction than a minor illness. But other things seldom are equal. Illness means different things to different people, and just because an illness is not life-threatening this does not mean the sufferer will be emotionally untouched by it. An individual who has never before experienced any significant illness, pain or discomfort may be upset by relatively minor symptoms which would seem insignificant to someone who has suffered a string of serious diseases.
Our emotional responses to illness can have a crucial bearing on our recovery and future health. If being ill makes us depressed we may become careless about adhering to our doctor’s advice or taking our medicine. This may, in turn, impede recovery. Whether or not a cancer patient adheres strictly to a programme of radiotherapy or chemotherapy can have a major impact on their chances of survival. There are patients who simply give up and sink into decline.
In extreme cases the emotional reaction to an illness can prove a bigger problem than the illness itself. Severe depression is far more debilitating and intrusive than many physical ailments. As we shall see in the next chapter, severe depression can also have detrimental effects on immune function and subsequent health, creating a spiral of decline. Doctors and patients ignore the psychological and emotional consequences of illness at their peril.
Finally, please do not go away with the impression that an individual’s perception of their own health is an entirely meaningless or deceptive index, indicating only their degree of hypochondria. On the contrary. Research has shown that in certain respects perception is a good guide to reality. Although our subjective judgement is not always an accurate index of our current state of health, it does provide a reasonably good predictor of our long-term risk of dying prematurely. Depressing though it may be if you are an arch hypochondriac, the research indicates that people who believe they are unhealthy do die younger on average. Moreover, perceptions are clearly important for practical and economic reasons: people’s perceptions of their health, rather than objective measures of health, are what largely determine their initial usage of medical facilities.
Bad behaviour
Sex and drugs and rock and roll
Is all my brain and body need
Ian Dury, ‘Sex and Drugs and Rock and Roll’ (1977)
A cousin of mine who was a casualty surgeon in Manhattan tells me that he and his colleagues had a one-word nickname for bikers: Donors. Rather chilling.
Stephen Fry, Paperweight (1992)
Our minds can have a profound impact on the physical health of our bodies by altering the way we behave. Psychological and emotional factors can dispose us to do all manner of unhealthy and self-destructive things. The self-destruction may be absolute and abrupt, as in suicide or fatal accidents, or gradual and cumulative, as in smoking.
Stress and anxiety, for example, can prevent us from sleeping properly and make us more inclined to smoke, drink excessive amounts of alcohol, eat too much of the wrong sorts of food, omit to take our medicine, neglect physical exercise, consume harmful recreational drugs, indulge in risky sexual behaviour, drive too fast without wearing a seat belt, have a violent accident, or even commit suicide (though not usually all at once).
Anna Karenin offers an impressive catalogue of self-destructive behaviour engendered by psychological and emotional trauma. Anna abandons her husband, the colourless bureaucrat Karenin, for the dynamic Count Vronsky. But their love is doomed and the emotional pressures on Anna build up to a fatal climax.
As a preamble to her eventual self-destruction, Anna nearly dies giving birth to Vronsky’s illegitimate daughter. In what she thinks are her final hours Anna appears to reconcile herself with her husband. Mad with emotional torment at this turn of events, Vronsky goes off and shoots himself – but not fatally. Although Vronsky is an army officer, and therefore presumably capable of hitting his own heart at point blank range, the bullet misses. He is seriously wounded – enough to make it a meaningful parasuicidal gesture – but does not die. Anna and the baby go to live with Vronsky, but her husband refuses to divorce her and she becomes a social outcast. The strain of her position renders Anna increasingly unstable and she develops paranoid delusions about Vronsky’s supposed unfaithfulness. Consumed by the madness of her passion, Anna suddenly decides that she must end her torment and punish Vronsky for his imagined misdeeds by killing herself. Anna famously ends her own life under the wheels of a train:
‘There,’ she said to herself, looking in the shadow of the trucks at the mixture of sand and coal dust which covered the sleepers. ‘There, in the very middle, and I shall punish him and escape from them all and from myself.’
And she does. And there is more. Almost insane with grief at Anna’s death, the bereaved Vronsky volunteers to fight, and very probably die, in a war between the Serbians and the Turks. Vronsky no longer places any value on his life and relishes the prospect of death: ‘I am glad there is something for which I can lay down the life which is not simply useless but loathsome to me. Anyone’s welcome to it …’
The melodrama of Anna Karenin’s suicide and Vronsky’s death wish are positively restrained in comparison with the high-camp posturings of Werther, the suicidal hero of Goethe’s The Sorrows of Young Werther. This eighteenth-century piece of unfettered Teutonic sentimentality tells the tragic tale of an unbalanced youth who tops himself after a bad dose of unrequited love.
The story is a simple but eternal one. Werther loves Lotte. Oh, how he loves her! But, alas, he cannot have her. Lotte is already promised to the worthy Albert and soon marries him, leaving Werther to wallow in emotional excess. He sheds a thousand tears one moment and ‘overflows with rapture’ the next, and each step on the way is recounted in copious letters to his long-suffering chum Wilhelm. So it comes as no surprise that, denied his one true love, Werther decides to end it all. Characteristically, his suicidal decision is reached only after much beating of chest, gnashing of teeth, shedding of tears and general languishing in melancholy, during which time an unkind reader might be forgiven for urging the lad to get on with it. Even when Werther finally does get round to pulling the trigger he takes several hours to die.
Incidentally, the tragic tale of young Werther had a fairly profound effect on the health of a number of readers. So resonant was Goethe’s writing with the romantic spirit of the times that the book triggered an epidemic of copy-cat suicides and was consequently banned in many places.2
All the leading causes of death in industrialized nations – including heart disease, cancer, accidental injury and AIDS – depend to some extent on how we behave. Smoking, eating habits, alcohol consumption, physical exercise, sleep patterns, sexual behaviour and choosing to wear a seatbelt, to name but a few, have ramifications for our health and wellbeing.
In industrialized societies, for example, accidental injuries and violence now account for at least half of all deaths among young men: a fact that is not wholly unrelated to the behavioural characteristics of young men. In extreme cases people who are very depressed or upset commit suicide or deliberately behave in a way which invites serious injury or death. Severe depression can lead to self-destructive behaviour. Besides making us act in positively unhealthy ways, psychological factors like anxiety, stress or depression can also inhibit us from engaging in activities that are beneficial to health, such as physical activity or social relationships with others.
In certain cases, such as crashing your car or committing suicide, the causal connection between behaviour and the subsequent damage to health is pretty obvious and requires no intimate knowledge of medical science to understand. Thanks to education and constant repetition in the media, less obvious connections between behaviour and health are also now widely recognized. The public accept that there are links between smoking and all manner of fatal diseases; between slothfulness and heart disease; between alcohol abuse and cirrhosis; and between unprotected sex and AIDS.
A stark illustration of how behaviour affects health is provided by AIDS. There are enormous geographical variations in the incidence of HIV infection and AIDS. For example, the incidence of AIDS in Honduras is fourteen times higher than in neighbouring Guatemala. Even within a single country or a single city there are massive variations in rates of infection between different social groups.
Since the HIV retrovirus was discovered to be the causal agent for AIDS in 1983 it has become clear that these large variations result primarily from differences in people’s behaviour – especially their sexual behaviour, which remains the route by which the virus is transmitted in the vast majority of HIV infections. It is generally accepted that a practical vaccine or cure for HIV/AIDS is at least a decade away.3 In the meantime, the only effective means available for limiting its spread is to change the way we behave.
There are plenty of commonplace behaviour patterns that kill people gradually but in huge numbers. Smoking is the prime example. As long ago as 1604 King James I, in his treatise A Counterblast to Tobacco, did not exactly pull his punches when he described the new-fangled habit of smoking as:
A custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs, and in the black, stinking fume thereof, nearest resembling the horrible Stygian smoke of the pit that is bottomless.
Smoking is the riskiest thing that most people will ever do in their lives. At present, smoking-related diseases account for 15–20 per cent of all deaths and result in over 100,000 premature deaths every year in Britain alone. Smoking greatly increases the risk of lung cancer, now the commonest fatal cancer in Britain. Smokers are ten times more likely to die from lung cancer than non-smokers and around 90 per cent of lung cancers are attributable to smoking.
Smoking also increases the risks of various other fatal or debilitating diseases including coronary heart disease (the biggest cause of death in most industrialized countries), chronic bronchitis, emphysema, and cancers of the oesophagus, bladder and pancreas. A quarter of all deaths from coronary heart disease are smoking-related. As if that were not enough, smoking causes birth complications and doubles the risk of a pregnant woman miscarrying.
Think about these statistics from the British Medical Association. The average risk that you will die from leukaemia within the next year is about 1 in 12,500. The average risk that you will die in a vehicle accident is 1 in 8,000. If you are, say, forty years old, your risk of dying from natural causes of any sort during the next twelve months is 1 in 850. However, if you smoke ten cigarettes a day your odds of dying within the year are 1 in 200. Or look at it another way: take a random sample of a thousand young men who smoke; on the basis of actuarial data it can confidently be predicted that one of these young men will eventually be murdered, six will be killed on the roads and two hundred and fifty will die prematurely from the effects of smoking.
Smoking is clearly bound up with what goes on in people’s minds. The reasons why individuals start smoking and why they then find it impossible to quit are neither simple nor well understood. Psychological studies of smokers have, however, confirmed the truth of several common assumptions.
It is indeed true that people who are depressed or stressed are more likely to smoke (and, consequently, more likely to die from lung cancer). Smokers really do experience a stronger desire to smoke at times of heightened anxiety. To add to their problems, psychological stress is associated with a higher failure rate among smokers trying to kick the habit. One long-term study of smokers found that individuals who had been depressed as much as nine years earlier were 40 per cent less likely to be successful in their attempts to give up smoking.
It gets worse. The psychological and emotional factors that make people inclined to smoke induce them to do other unhealthy things as well. Research has shown that moderate-to-heavy smokers are, on average, significantly less conscious of health-related issues, hold less favourable attitudes towards healthy behaviour and have a generally less healthy lifestyle in comparison with non-smokers or light smokers. (Conversely, wholesome behaviour patterns also come in clusters; researchers at Harvard University Medical School found that individuals who drank only decaffeinated coffee also tended to eat lots of vegetables, take regular exercise and wear their seatbelts.)
As well as prompting people to smoke, stress is also linked to increased alcohol consumption – at least, in certain types of individual. The health implications of excessive drinking can be profound. Approximately 20 per cent of all male in-patients in British hospitals have alcohol-related problems. Alcohol can rot people’s livers and kill them in drunken accidents (though alcohol is not the only recreational drug capable of damaging health: there is reasonably good evidence, for example, that marijuana impairs the immune system, with potentially adverse consequences for the health of long-term users.)
The perils of the grape are amusingly described in Othello. The scheming Iago lures the unwitting Cassio into getting steamingly drunk, as a result of which Cassio lands himself in serious trouble and loses his job. On sobering up, Cassio bemoans the loss of his reputation and curses the demon drink:
‘Drunk! And speak parrot! And squabble! Swagger! Swear! And discourse fustian with one’s own shadow! O thou invisible spirit of wine, if thou hast no name to be known by, let us call thee devil! … O God, that men should put an enemy in their mouths to steal away their brains! That we should with joy, pleasance, revel and applause, transform ourselves into beasts!’
Literature is amply stocked with characters who drink themselves into an early grave in reaction to emotional crisis or unhappiness. There are roistering drunks who drink to escape boredom or poverty, like J. P. Donleavy’s Ginger Man, Sebastian Dangerfield. There are determined drunks who drink to escape from grief. In Wuthering Heights, the unfortunate Hindley Earnshaw becomes a hopeless alcoholic after the death of his wife (from consumption, naturally) and drinks himself into the grave by the age of twenty-seven. And there are aimless drunks who drink to forget their own pointlessness. In F. Scott Fitzgerald’s The Beautiful and Damned, for example, we have Anthony Patch, an independently wealthy and well-educated young man blighted by indolence, boredom and melancholy. A turbulent marriage and self-imposed idleness push him into self-destructive alcoholism and he degenerates into ‘Anthony the poor in spirit, the weak and broken man with bloodshot eyes’.
Incidentally, when it comes to self-destruction by alcohol the track record of doctors is almost unrivalled. As a profession, they rank second only to pub-owners and bar staff in the league table of deaths from alcohol-related liver disease. Doctors are 3.4 times more likely than the average worker to die from cirrhosis of the liver. According to one 1995 estimate, as many as one in twelve British doctors is addicted to alcohol, drugs or both, thanks mainly to the enormous stress the majority of them are constantly under. (But I should not be too smug about this statistic because ‘literary and artistic workers’ also fare badly, with twice the average death rate from cirrhosis.)
On the other hand, moderate alcohol consumption can be an effective buffer against stress – and here again science has only of late managed to verify thousands of years’ worth of everyday experience. Psychological studies have confirmed what countless millions of people have discovered for themselves, namely that when we are under stress we often feel less anxious if we drink alcohol. (A moderate intake of alcohol also appears to reduce the risk of coronary heart disease, but that is another story.) Sir Winston Churchill’s opinion was clear: ‘I have taken more out of alcohol than alcohol has taken out of me.’
There is nothing surprising about the fact that alcohol has its good side. It has, after all, been an intimate part of human life since the dawn of civilization. Alcohol was in use for medicinal purposes (in the literal rather than euphemistic sense) over four thousand years ago and was probably quaffed for recreational purposes long before that.
Opinions differ as to when exactly humans first discovered the joys of booze, but there is evidence that wine was being drunk in Transcaucasia eight thousand years ago – long before the wheel was invented. Some authorities have argued that Stone Age man was cultivating vines as early as ten thousand years ago. Wine growing was well established in the Middle East by 4000 BC and was an integral part of daily life in ancient Egypt and Mesopotamia. It says something that wine is mentioned 150 times in the Old Testament.
Then there are the social benefits of communal drinking to add to the purely pharmacological pleasures of alcohol. Samuel Johnson spoke for many when he declared that: ‘There is nothing which has yet been contrived by man, by which so much happiness is produced as by a good tavern or inn.’
Yet the things that give us pleasure carry risks, and we are very poor at assessing those risks. While we consistently overestimate the dangers posed by rare or exotic threats like plane crashes, murders, nuclear accidents or shark attacks, we tend to disregard the risks of common killers like heart disease and vehicle accidents. We are especially prone to underestimating the risks arising from our own behaviour, such as smoking, travelling in cars, abusing alcohol or having unprotected sex.
Smokers now acknowledge the unappetizing fact that their behaviour significantly increases their risk of dying prematurely from heart disease or cancer. Nevertheless, psychological research has established that they seriously underestimate the magnitude of that risk. There is a consistent ‘optimistic distortion’ of perceived health risks among smokers; they know smoking is bad for them but they do not recognize just how bad. No matter how often the statistics are quoted they do not seem to sink in. One reason why the health consequences of smoking have such a muted impact on people’s perceptions is the large delay, often measured in decades, between starting to smoke and falling ill.
If you should happen to be an overweight, tobacco-addicted, boozing, couch potato who loves fried food, you can take a few crumbs of comfort from the fact that others’ attempts at healthy living can backfire. Dieting, for example, almost invariably fails to bring about the desired result of sustained weight loss. The sense of personal failure that comes as the scales lurch upwards again can produce a damaging drop in self-esteem and a sense of losing control; the frustrated dieter’s response may be to abandon the diet and thus swing back to even greater porkiness. Mother Nature also conspires against the earnest dieter. People whose body weight oscillates because of dieting have a greater risk of premature death from coronary heart disease or other causes. Unsuccessful dieting can be bad for your health – and most dieting is ultimately unsuccessful.