June 2014

The Medicine

Medicine and the mind-body problem

By Karen Hitchcock
What is sickness, and how much of it is in our heads?

I was recently asked to give a presentation about “what makes us sick”. Thinking about that question nearly made my head explode. It’s more like “What doesn’t make us sick?”

My big inner-city hospital is overflowing with the sick. There are people who are in the orthopaedic ward because they got up for a glass of water and snapped their hip. The psychiatry ward is full of near suicides and patients whose phantom voices are drilling holes in their heads. The cardiac lab is full of heart attacks. The burns unit usually has one or two people a year who tipped a bucket of petrol over their head and struck a match. We house the frail and the elderly, the drunken and the overdosed. Organs are plucked from the brain dead and sewn into the diseased. People crowd the emergency department, suffering because their organs are slowly failing their bodies. What made them sick? What is sickness, anyway?

Besides looking after in-patients, I also work in three public outpatient clinics at the hospital. One is for patients – mostly elderly – who have multiple health problems. Another clinic is for the morbidly obese and the third is a fatigue clinic.

A doctor’s job is to treat and protect diseased and threatened organs – those beautiful, intricate, faithful organs that pump and squeeze and metabolise away, mostly quietly, keeping us alive. Sick organs. Just treat them, doc, and go home. How hard can it be? But doctors don’t sit in their chairs facing livers and hearts. We encounter complex, conflicted, imperfect, suffering people with their specific histories, needs, cultures and understandings of sickness and health.

Being alive has its difficulties. Even for those who are relatively wealthy, with access to all the physical necessities, living demands payment of an existential debt. We live with the knowledge that we are going to die. We suffer unbearable losses. We hurt in all sorts of ways. And because we are alive, we do things that damage our bodies and make us sick. I have had patients who can barely breathe because of their lung disease tell me they cannot quit smoking as it’s their only friend. We smoke, we drink, we over-eat. We engage in all manner of risky activities, trading aliquots of our life in exchange for things that give us pleasure or make life bearable.

A registrar told me recently that her PhD topic was the appetite of rats. The results, she claimed, were applicable to humans. “Their brains are almost exactly the same as humans’!” I looked around our ward. In medical research we are rats, we are robots, we are a bunch of organs bound by skin. We have no mind, no unconscious. We have no dreams or hopes or existential pain.

But we are more than organs bound by skin. We are more than rats in cages. We have gigantic mental lives – conscious and unconscious. We each bear our sickness in our particular way. Suffering, for each person, has different meanings and manifestations. Most of the patients who come to the fatigue clinic have been seen by many, many doctors. They’ve had every part of their bodies probed, scoped and scanned. They’ve been cupped, pricked, starved, and infused with harmful megavitamins. They have pain, fatigue, paralysis. They can’t get out of bed. They’ve abandoned their dreams because they are sick. But they are not “clinically depressed”. And their organs are intact, pristine.

“But doctor, there is something wrong with my body and no one can find what it is.” Approximately 30 to 50% of patients attending specialist clinics have symptoms that have no organic cause. That is, they are psychosomatic in origin, “all in their head”. In medicine we call these unexplained debilitating symptoms “functional”. The patient, we say, has a “functional” disorder.

Unfortunately, in medicine, in theory, in popular culture and society, we’ve disconnected the mind or psyche from the body and chucked the psyche part away. So if you are sick, the thing making you feel that way must be in there somewhere – a bug, an intolerance, a toxin, a lump of rot – and you go to see doctors who scan you and sample you and test you and find nothing. Your symptom is then labelled “functional” and you are sent home. A lot of terrible disability, sickness and waste remains untreated or maltreated because everyone – except that ever-dwindling enclave of psychoanalysts – has abandoned an understanding of the human being as more than robotic, more than animal, more than genes plus protein and water.

Modern psychiatry has reduced the wonders of our mental life to the mush of the brain. For treating the brain, the organ, is prestigious. Having something wrong with your body is prestigious, because the psyche’s been relegated to the bin. We have lost – in medicine and everywhere else – the understanding of the human as a complex, language-bound mix of consciousness and unconsciousness whose bodily suffering may have meanings and functions we cannot interpret via a blood test. We call these illnesses “functional” but have stopped questioning what exactly the “function” of them may be for the patient.

There’s an epidemic. We can’t name it or see it or treat it because we no longer have the language we’d need to do this. And so we can’t help these people. And so we hand out a barely-better-than-placebo antidepressant. We’ve let ourselves be reduced to lab rats. But don’t blame the doctor (though it’s evidently a fun sport), because the patients don’t want a psychoanalyst, they want a physical diagnosis and a pill. Don’t blame medicine, for it is all of us who have decided that dreams are debris, that a symptom generated “in your head” is merely counterfeit and that sickness is always caused by a thing.

Karen Hitchcock

Karen Hitchcock is a doctor and writer. She is the author of a collection of short fiction, Little White Slips, and the Quarterly Essay Dear Life: On Caring for the Elderly.

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