The Sickening Mind: Brain, Behaviour, Immunity and Disease. Paul Martin

when it comes to assessing our state of health. The perceptions of those around us can also play an important role. Social pressures can reinforce, or even create, the perception that we are ill.

      Imagine you are under a lot of stress. (Perhaps you don’t have to imagine.) You have been told you are going to lose your job, your partner has left you and your personal finances are in meltdown. Unless you are exceptionally self-possessed your behaviour patterns will change noticeably. Perhaps you no longer relish the prospect of going for a drink with your friends; you feel depressed so you decline social invitations; you sleep badly and come to work looking tired; you are preoccupied with your problems and your performance accordingly suffers; you become irritable or keep bursting into tears; you go off your food and lose weight, or perhaps you turn to comfort feeding and pile on the calories instead.

      Your friends and colleagues notice these changes and comment on them. They keep remarking that you don’t look well; it must be the stress; perhaps you should see a doctor. Come to think of it, you don’t feel too marvellous. Those headaches and the constant fatigue might be significant, and you have lost weight.

      Before long you have convinced yourself that you are ill. You have certainly read enough magazine articles to know that stress is bad for your health. You take to your bed, or perhaps you trot off to see your doctor. To put it in the language of social psychology, social pressures have encouraged you to take on the ‘sick role’. Now, you may indeed be genuinely ill; as we shall see, there is no doubt that stress can make us more susceptible to disease. But the thought processes that have led you to the conclusion that you are ill were driven largely by social pressure. Other people’s minds, as well as your own, were involved in the process.

      Consider, for example, the case of Colin Craven – the hypochondriac from hell in Frances Hodgson Burnett’s children’s classic The Secret Garden.

      The obnoxious, bedridden Colin has been treated as an invalid, doomed to an early death, for all of his ten years. Everyone in Colin’s orbit unquestioningly accepts that he is destined to be a crippled hunchback – that is, if he lives at all. They continually reinforce Colin’s belief in his illness, reminding him of his weakness and urging him to rest. As one would expect, lying in bed all day has had a seriously debilitating effect on Colin’s muscles; on the rare occasions when he does get up he feels genuinely feeble.

      The egregious brat lies in bed all day with the family retainers pandering to his every whim. The servants live in fear of Colin’s hysterical tantrums and dare not contradict him. The housekeeper privately recognizes that Colin is a victim of self-indulgence and hypochondria but would not dream of saying this to his face. To make matters worse, Colin’s doctor is next in line to inherit the family property should Colin die and is therefore less than objective about the child’s health. A London doctor who has had the temerity to suggest that Colin is not ill has been studiously ignored. Colin is immersed in his all-consuming hypochondria and sublimely unaware of how spoilt and unreasonable he is. Until his cousin Mary arrives.

      Mary (who is not the nicest of children herself) rubbishes Colin’s alleged medical condition during a fit of pique. She tells Colin bluntly that he has no trace of a lump on his back and is just being hysterical.

      By challenging the unquestioned belief in Colin’s illness, Mary has an electric effect on him. The supposed invalid soon comes to realize that there isn’t anything wrong with him beyond his morbid state of mind. There is no lump on his back; he is thin and pallid because he refuses to eat properly; and he is weak because he lies in bed all day.

      So long as Colin shut himself up in his room and thought only of his fears and weakness and his detestation of people who looked at him and reflected hourly on humps and early death, he was a hysterical, half-crazy little hypochondriac who knew nothing of the sunshine and the spring, and also did not know that he could get well and stand upon his feet if he tried to do it. When new, beautiful thoughts began to push out the old, hideous ones, life began to come back to him, his blood ran healthily through his veins and strength poured into him like a flood.

      With the help of cousin Mary, her rosy-cheeked proletarian chum Dickon and, of course, the Secret Garden, Colin is soon transformed into a ‘laughable, loveable, healthy young human thing’ who announces to the world that he is going to ‘live for ever and ever and ever’.

      A more delicate literary example of an indeterminate illness born of circumstance can be found in Tolstoy’s Anna Karenin. Young Kitty Shcherbatsky declines an offer of marriage from the worthy but unworldly Levin, expecting instead to receive a proposal from the dashing Count Vronsky. When Vronsky’s anticipated proposal fails to materialize, Kitty, like a good nineteenth-century heroine, goes into a severe physical and mental decline which lasts for months. It is serious stuff and everyone is worried about the poor girl’s health. Kitty’s family doctor discusses her condition with a celebrated specialist whose help has been enlisted by the worried family:

      ‘But of course you know that in these cases there is always some hidden moral and emotional factor’, the family physician allowed himself to remark with a faint smile.

      ‘Yes, that goes without saying’, replied the celebrated specialist …

      Kitty’s family and friends are worried even though they are well aware that her condition has essentially psychological origins. Kitty is described as ‘ill for love of a man who had slighted her.’ Kitty’s health does not improve and it is feared that she might actually die. Her anxious parents therefore take her on a foreign tour, where she encounters another young lady whose illness is also ‘due to a love affair’. The passage of time and the distractions offered by foreign travel eventually bring about Kitty’s recovery. Her illness and absence also allow circumstances to develop in her favour; she returns to Russia, marries the faithful Levin and (unlike the eponymous Anna) lives happily ever after.

      Another way in which mental processes intrude into the domain of physical health is through the universal need for legitimacy. When we have decided that we are ill we want other people, and especially our doctor, to accept that we really are ill and not just malingering or being neurotic. Whether consciously or unconsciously, we want our putative disease to be accepted as genuine and not dismissed as a product of our fevered imagination. We need to legitimize our sickness by presenting the doctor with symptoms that will be accepted as evidence of a known organic disease. After all, no diagnosis means no treatment. As we saw in chapter 1, this can be a real problem for those suffering from poorly understood and controversial disorders such as chronic fatigue syndrome.

      In his fascinating historical study From Paralysis to Fatigue, Edward Shorter has described how the physical symptoms that characterize so-called psychosomatic illnesses – those vague, undiagnosable ailments whose physical causes prove so elusive – have evolved over the years to keep pace with changing ideas about what constitutes a genuine disease. As society’s perceptions and beliefs about disease have changed, so the symptoms of psychosomatic illness have also changed to keep pace with what is regarded as legitimate evidence of disease. Thus, in the eighteenth and nineteenth centuries it was common for people to succumb to hysterical paralysis, convulsions or ‘fits of the vapours’. Paralysis of the legs was positively de rigueur among well-to-do young ladies of the nineteenth century. Nowadays, some would regard the symptoms of chronic fatigue and allergies as falling into the same category.

      Shorter’s historical analysis is interesting in that it demonstrates the powerful effect social pressures and cultural norms can have on patterns of symptoms. Actual diseases are another matter, however. There is nothing imaginary or unreal about many cases of chronic fatigue syndrome, allergies or other supposedly fashionable illnesses.

      Our expectations also have an important influence on our perception of health. In industrialized societies like Britain and the USA general expectations of health have risen considerably in recent decades and continue to rise. As in so many other spheres of human activity, a consumerist attitude towards health has become the norm. People demand more in terms of their physical and mental wellbeing and are less willing to tolerate minor health problems which detract from their quality of life. That elusive – and probably illusory – gold standard of total health is increasingly