When the Body Says No: The Cost of Hidden Stress (2 page)

Only an intellectual Luddite would deny the enormous benefits that have accrued to humankind from the scrupulous application of scientific methods. But not all essential information can be confirmed in the laboratory or by statistical analysis. Not all aspects of illness can be reduced to facts verified by double-blind studies and by the strictest scientific techniques. “Medicine tells us as much about the meaningful performance of healing, suffering and dying as chemical analysis tells us about the aesthetic value of pottery,” Ivan Ilyich wrote in
Limits to Medicine
. We confine ourselves to a narrow realm indeed if we exclude from accepted knowledge the contributions of human experience and insight.

We have lost something. In 1892 the Canadian William Osler, one of the greatest physicians of all time, suspected rheumatoid arthritis—a condition related to scleroderma—to be a stress-related disorder. Today rheumatology all but ignores that wisdom, despite the supporting scientific evidence accumulated in the 110 years since Osler first published his text. That is where the narrow scientific approach has brought the practice of medicine. In elevating modern science to be the final arbiter of our sufferings, we have been too eager to discard the insights of previous ages.

As the American psychologist Ross Buck has pointed out, until the advent of modern medical technology and of scientific pharmacology, physicians traditionally had to rely on “placebo” effects. They had to inspire in each patient a confidence in his, the patient’s, inner ability to heal. To be effective, a doctor had to listen to the patient, to develop a relationship with him, and he had also to trust his own intuitions. Those are the qualities doctors seem to have lost as we have come to rely almost exclusively on “objective” measures, technology-based diagnostic methods and “scientific” cures.

Thus the rebuke from the rheumatologist was not a surprise. More of a jolt was another letter to the editor, a few days later—this time a supportive one—from Noel B. Hershfield, clinical professor of medicine at the University of Calgary: “The new discipline of psychoneuroimmunology has now matured to the point where there is compelling evidence, advanced by scientists from many fields, that an intimate relationship exists between the brain and the immune system…. An individual’s emotional makeup, and the response to continued stress, may indeed be causative in the many diseases that medicine treats but whose [origin] is not yet known—diseases such as scleroderma, and the vast majority of rheumatic disorders, the inflammatory bowel disorders, diabetes, multiple sclerosis, and legions of other conditions which are represented in each medical subspecialty….”

The surprising revelation in this letter was the existence of a new field of medicine. What is
psychoneuroimmunology?
As I learned, it is no less than the science of the interactions of mind and body, the indissoluble unity of emotions and physiology in human development and throughout life in health and illness. That dauntingly complicated word means simply that this discipline studies the ways that the psyche—the
mind and its content of emotions—profoundly interacts with the body’s nervous system and how both of them, in turn, form an essential link with our immune defences. Some have called this new field
psychoneuroimmunoendocrinology
to indicate that the endocrine, or hormonal, apparatus is also a part of our system of whole-body response. Innovative research is uncovering just how these links function all the way down to the cellular level. We are discovering the scientific basis of what we have known before and have forgotten, to our great loss.

Many doctors over the centuries came to understand that emotions are deeply implicated in the causation of illness or in the restoration of health. They did research, wrote books and challenged the reigning medical ideology, but repeatedly their ideas, explorations and insights vanished in a sort of medical Bermuda Triangle. The understanding of the mind-body connection achieved by previous generations of doctors and scientists disappeared without a trace, as if it had never seen daylight.

A 1985 editorial in the august
New England Journal of Medicine
could declare with magisterial self-assurance that “it is time to acknowledge that our belief in disease as a direct reflection of mental state is largely folklore.”
²

Such dismissals are no longer tenable. Psychoneuroimmunology, the new science Dr. Hershfield mentioned in his letter to the
The Globe and Mail
, has come into its own, even if its insights have yet to penetrate the world of medical practice.

A cursory visit to medical libraries or to online sites is enough to show the advancing tide of research papers, journal articles and textbooks discussing the new knowledge. Information has filtered down to many people in popular books and magazines. The lay public, ahead of the professionals in many ways and less shackled to old orthodoxies, finds it less threatening to accept that we cannot be divided up so easily and that the whole wondrous human organism is more than simply the sum of its parts.

Our immune system does not exist in isolation from daily experience. For example, the immune defences that normally function in healthy young people have been shown to be suppressed in medical students under the pressure of final examinations. Of even greater implication for their future health and well-being, the loneliest students suffered the greatest negative impact on their immune systems. Loneliness has been
similarly associated with diminished immune activity in a group of psychiatric inpatients. Even if no further research evidence existed—though there is plenty—one would have to consider the long-term effects of chronic stress. The pressure of examinations is obvious and short term, but many people unwittingly spend their entire lives as if under the gaze of a powerful and judgmental examiner whom they must please at all costs. Many of us live, if not alone, then in emotionally inadequate relationships that do not recognize or honour our deepest needs. Isolation and stress affect many who may believe their lives are quite satisfactory.

How may stress be transmuted into illness? Stress is a complicated cascade of physical and biochemical responses to powerful emotional stimuli. Physiologically, emotions are themselves electrical, chemical and hormonal discharges of the human nervous system. Emotions influence—and are influenced by—the functioning of our major organs, the integrity of our immune defences and the workings of the many circulating biological substances that help govern the body’s physical states. When emotions are repressed, as Mary had to do in her childhood search for security, this inhibition disarms the body’s defences against illness. Repression—dissociating emotions from awareness and relegating them to the unconscious realm—disorganizes and confuses our physiological defences so that in some people these defences go awry, becoming the destroyers of health rather than its protectors.

During the seven years I was medical coordinator of the Palliative Care Unit at Vancouver Hospital, I saw many patients with chronic illness whose emotional histories resembled Mary’s. Similar dynamics and ways of coping were present in the people who came to us for palliation with cancers or degenerative neurological processes like amyotrophic lateral sclerosis (ALS, also known in North America as Lou Gehrig’s disease, after the great American baseball player who succumbed to it, and in Britain as motor neuron disease.) In my private family practice, I observed these same patterns in people I treated for multiple sclerosis, inflammatory ailments of the bowel such as ulcerative colitis and Crohn’s disease, chronic fatigue syndrome, autoimmune disorders, fibromyalgia, migraine, skin disorders, endometriosis and many other conditions. In important areas of their lives, almost none of my patients with serious disease had ever learned to say no. If some people’s
personalities and circumstances appeared very different from Mary’s on the surface, the underlying emotional repression was an ever-present factor.

One of the terminally ill patients under my care was a middle-aged man, chief executive of a company that marketed shark cartilage as a treatment for cancer. By the time he was admitted to our unit, his own recently diagnosed cancer had spread throughout his body. He continued to eat shark cartilage almost to the day of his death, but not because he any longer believed in its value. It smelled foul—the offensive stench was noticeable even some distance away—and I could only imagine what it tasted like. “I hate it,” he told me, “but my business partner would be so disappointed if I stopped.” I convinced him that he had every right to live his last days without feeling responsible for someone else’s disappointment.

It is a sensitive matter to raise the possibility that the way people have been conditioned to live their lives may contribute to their illness. The connections between behaviour and subsequent disease are obvious in the case of, say, smoking and lung cancer—except perhaps to tobacco-industry executives. But such links are harder to prove when it comes to emotions and the emergence of multiple sclerosis or cancer of the breast or arthritis. In addition to being stricken with disease, the patient feels blamed for being the very person she is. “Why are you writing this book?” said a fifty-two-year-old university professor who has been treated for breast cancer. In a voice edged with anger she told me, “I got cancer because of my genes, not because of anything I did.”

“The view of sickness and death as a personal failure is a particularly unfortunate form of blaming the victim,” charged the 1985 editorial in the
New England Journal of Medicine
. “At a time when patients are already burdened by disease, they should not be further burdened by having to accept responsibility for the outcome.”

We will return to this vexing question of assumed blame. Here I will only remark that blame and failure are not the issue. Such terms only cloud the picture. As we shall see, blaming the sufferer—apart from being morally obtuse—is completely unfounded from a scientific point of view.

The
NEJM
editorial confused blame and responsibility. While all of us dread being
blamed
, we all would wish to be more
responsible
—that is, to have the ability to
respond
with awareness to the circumstances of our
lives rather than just reacting. We want to be the authoritative person in our own lives: in charge, able to make the authentic decisions that affect us. There is no true responsibility without awareness. One of the weaknesses of the Western medical approach is that we have made the physician the only authority, with the patient too often a mere recipient of the treatment or cure. People are deprived of the opportunity to become truly responsible. None of us are to be blamed if we succumb to illness and death. Any one of us might succumb at any time, but the more we can learn about ourselves, the less prone we are to become passive victims.

Mind and body links have to be seen not only for our understanding of illness but also for our understanding of health. Dr. Robert Maunder, on the psychiatric faculty of the University of Toronto, has written about the mind-body interface in disease. “Trying to identify and to answer the question of stress,” he said to me in an interview, “is more likely to lead to health than ignoring the question.” In healing, every bit of information, every piece of the truth, may be crucial. If a link exists between emotions and physiology,
not
to inform people of it will deprive them of a powerful tool.

And here we confront the inadequacy of language. Even to speak about links between mind and body is to imply that two discrete entities are somehow connected to each other. Yet in life there is no such separation; there is no body that is not mind, no mind that is not body. The word
mindbody
has been suggested to convey the real state of things.

Not even in the West is mind-body thinking completely new. In one of Plato’s dialogues, Socrates quotes a Thracian doctor’s criticism of his Greek colleagues: “This is the reason why the cure of so many diseases is unknown to the physicians of Hellas; they are ignorant of the whole. For this is the great error of our day in the treatment of the human body, that physicians separate the mind from the body.”
³
You cannot split mind from body, said Socrates—nearly two and a half millennia before the advent of psychoneuroimmunoendocrinology!

Writing
When the Body Says No
has done more than simply confirm some of the insights I first articulated in my article about Mary’s scleroderma. I have learned a great deal and have come to appreciate deeply the work of hundreds of physicians, scientists, psychologists and researchers who have charted the previously unmapped terrain of
mind-body. Work on this book has also been an inner exploration of the ways I have repressed my own emotions. I was prompted to make this personal journey in response to a question from a counsellor at the British Columbia Cancer Agency, where I had gone to investigate the role of emotional repression in cancer. In many people with malignancy, there seemed to be an automatic denial of psychic or physical pain and of uncomfortable emotions like anger, sadness or rejection. “Just what is your personal connection to the issue?” the counsellor asked me. “What draws you to this particular topic?”

The question brought to mind an incident from seven years ago. One evening I arrived to see my seventy-six-year-old mother at the nursing home where she was a resident. She had progressive muscular dystrophy, an inherited muscle-wasting disease that runs in our family. Unable to even sit up without assistance, she could no longer live at home. Her three sons and their families visited her regularly until her death, which occurred just as I began to write this book.

I had a slight limp as I walked down the nursing home corridor. That morning I had undergone surgery for a torn cartilage in my knee, a consequence of ignoring what my body had been telling me in the language of pain that occurred each time I jogged on cement. As I opened the door to my mother’s room, I automatically walked with a nonchalant, normal gait to her bed to greet her. The impulse to hide the limp was not conscious, and the act was done before I was aware of it. Only later did I wonder what exactly had prompted such an unnecessary measure—unnecessary because my mother would have calmly accepted that her fifty-one-year-old son would have a gimpy knee twelve hours post-surgery.